pain management for women in labour: an overview of

Pain management for women in labour: an overview of

systematic reviews (Review)

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T,

Neilson JP

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2012, Issue 3

http://www.thecochranelibrary.com

Pain management for women in labour: an overview of systematic reviews (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

27DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

158APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iPain management for women in labour: an overview of systematic reviews (Review)


[Overview of Reviews]

Pain management for women in labour: an overview ofsystematic reviews

Leanne Jones1, Mohammad Othman1, Therese Dowswell1, Zarko Alfirevic2, Simon Gates3, Mary Newburn4, Susan Jordan5, Tina

Lavender6, James P Neilson2

1Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool,

UK. 2Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK. 3Warwick Clinical Trials Unit,

Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK. 4National Childbirth Trust, Acton,

London, UK. 5Department of Nursing, Swansea University, Swansea, UK. 6School of Nursing, Midwifery and Social Work, The

University of Manchester, Manchester, UK

Contact address: James P Neilson, Department of Women’s and Children’s Health, The University of Liverpool, First Floor, Liverpool

Women’s NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. [email protected].

Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: Edited (no change to conclusions), published in Issue 6, 2013.

Review content assessed as up-to-date: 31 October 2011.

Citation: Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management

for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234.

DOI: 10.1002/14651858.CD009234.pub2.


A B S T R A C T

Background

The pain that women experience during labour is affected by multiple physiological and psychosocial factors and its intensity can vary

greatly. Most women in labour require pain relief. Pain management strategies include non-pharmacological interventions (that aim

to help women cope with pain in labour) and pharmacological interventions (that aim to relieve the pain of labour).

Objectives

To summarise the evidence from Cochrane systematic reviews on the efficacy and safety of non-pharmacological and pharmacological

interventions to manage pain in labour. We considered findings from non-Cochrane systematic reviews if there was no relevant Cochrane

review.

Methods

We searched the Cochrane Database of Systematic Reviews (The Cochrane Library 2011, Issue 5), The Cochrane Database of Abstracts

of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to 31 May 2011) and EMBASE (1974 to 31 May

2011) to identify all relevant systematic reviews of randomised controlled trials of pain management in labour. Each of the contributing

Cochrane reviews (six new, nine updated) followed a generic protocol with 13 common primary efficacy and safety outcomes. Each

Cochrane review included comparisons with placebo, standard care or with a different intervention according to a predefined hierarchy

of interventions. Two review authors extracted data and assessed methodological quality, and data were checked by a third author. This

overview is a narrative summary of the results obtained from individual reviews.

Main results

We identified 15 Cochrane reviews (255 included trials) and three non-Cochrane reviews (55 included trials) for inclusion within

this overview. For all interventions, with available data, results are presented as comparisons of: 1. Intervention versus placebo or

1Pain management for women in labour: an overview of systematic reviews (Review)


mailto:[email protected]

standard care; 2. Different forms of the same intervention (e.g. one opioid versus another opioid); 3. One type of intervention

versus a different type of intervention (e.g. TENS versus opioid). Not all reviews included results for all comparisons. Most reviews

compared the intervention with placebo or standard care, but with the exception of opioids and epidural analgesia, there were few direct

comparisons between different forms of the same intervention, and even fewer comparisons between different interventions. Based on

these three comparisons, we have categorised interventions into: “ What works” ,“What may work”, and “Insufficient evidence to make

a judgement”.

WHAT WORKS

Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may

give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of

intervention (epidural versus opioids). Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals.

Women receiving inhaled analgesia were more likely to experience vomiting, nausea and dizziness.

When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean

sections for fetal distress, although there was no difference in the rates of caesarean section overall. Women receiving epidural analgesia

were more likely to experience hypotension, motor blockade, fever or urinary retention. Less urinary retention was observed in women

receiving CSE than in women receiving traditional epidurals. More women receiving CSE than low-dose epidural experienced pruritus.

WHAT MAY WORK

There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or

non-opioid drugs may improve management of labour pain, with few adverse effects. Evidence was mainly limited to single trials.

These interventions relieved pain and improved satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic

nerve blocks, non-opioids) and childbirth experience (immersion, relaxation, non-opioids) when compared with placebo or standard

care. Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and

caesarean sections.

INSUFFICIENT EVIDENCE

There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy,

TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour. In comparison

with other opioids more women receiving pethidine experienced adverse effects including drowsiness and nausea.

Authors’ conclusions

Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their

efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and

the overall methodological quality of the trials was low. High quality trials are needed.

There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia

provides effective pain relief but at the cost of increased instrumental vaginal birth.

It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour,

the infant’s condition, and any augmentation or induction of labour.

A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use

of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate

after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence.

Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of

maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57

trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through

wide consultation for this project, are used in all future trials of methods of pain management.

P L A I N L A N G U A G E S U M M A R Y

Pain management for women in labour - an overview



Women’s experience of pain during labour varies greatly. Some women feel little pain whilst others find the pain extremely distressing.

A woman’s position in labour, mobility, and fear and anxiety or, conversely, confidence may influence her experience of pain. Several

drug and non-drug interventions are available, and in this overview we have assessed 18 systematic reviews of different interventions

used to reduce pain in labour, 15 of these being Cochrane reviews.

Most of the evidence on non-drug interventions was based on just one or two studies and so the findings are not definitive. However,

we found that immersion in water, relaxation, acupuncture and massage all gave pain relief and better satisfaction with pain relief.

Immersion and relaxation also gave better satisfaction with childbirth. Both relaxation and acupuncture decreased the use of forceps

and ventouse, with acupuncture also decreasing the number of caesarean sections. There was insufficient evidence to make a judgement

on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, and TENS are effective for pain relief in labour.

Overall, there were more studies of drug interventions. Inhaled nitrous oxide and oxygen (Entonox®) relieved pain, but some women

felt drowsy, nauseous or were sick. Non-opioid drugs (e.g. sedatives) relieved pain and some gave greater satisfaction with pain relief

than placebo or no treatment, but satisfaction with pain relief was less than with opioids. Epidurals relieved pain, but increased the

numbers of births needing forceps or ventouse, and the risk of low blood pressure, motor blocks (hindering leg movement), fever and

urine retention. Combined spinal-epidurals gave faster pain relief but more women had itching than with epidurals alone, although

urinary retention was less likely to be a problem. Local anaesthetic nerve blocks gave satisfaction but caused side effects of giddiness,

sweating, tingling, and more babies had low heart rates. Parenteral opioids (injections of pethidine and related drugs) are less effective

than epidural but there was insufficient evidence to make a judgement on whether or not they are more effective than other interventions

for pain relief in labour.

Overall, women should feel free to choose whatever pain management they feel would help them most during labour. Women who

choose non-drug pain management should feel free, if needed, to move onto a drug intervention. During pregnancy, women should be

told about the benefits and potential adverse effects on themselves and their babies of the different methods of pain control. Individual

studies showed considerable variation in how outcomes such as pain intensity were measured and some important outcomes were rarely

or never included (for example, sense of control in labour, breastfeeding, mother and baby interaction, costs and infant outcomes).

Further research is needed on the non-drug interventions for pain management in labour.

B A C K G R O U N D

History

In 2007, 78% of the members of the Cochrane Pregnancy and

Childbirth Group (PCG) consumers’ group identified pain relief

in labour as the topic of most importance to them. In view of the

range of different interventions and the importance of the topic,

the Cochrane PCG recognised that an overview of this topic was

needed. In 2010 we obtained funding as part of the National In-

stitute for Health Research (NIHR) Cochrane-NHS Engagement

Scheme to produce a generic protocol for reviews examining dif-

ferent interventions to manage pain in labour and to produce an

overview summarising the evidence from the individual reviews

in a single publication. At the time of writing, 15 Cochrane re-

views focus on methods to manage pain in labour. It is envisaged

that the overview will provide a coherent and accessible summary

of the totality of evidence about the topic, reducing or obviating

the need for readers to access each individual systematic review.

The generic protocol for the individual reviews has been published

within The Cochrane Library.The development of the overview protocol involved active consul-

tation with members of the Cochrane PCG, authors of individual

reviews and consumers. The methods were derived from Chapter

22 of the Cochrane Handbook of Systematic Reviews of Interventions(Higgins 2011). The list of core outcomes was developed in collab-

oration with members of the PCG consumers’ group; 14 respon-

dents prioritised outcomes from an extended list and added any

further outcomes that were of importance to them. This revised

set of outcomes was then discussed at a meeting on 4 October

2010 of stakeholders representing The Cochrane Collaboration,

the Cochrane PCG, an NCT (formerly National Childbirth Trust)

representative and researchers experienced in systematic reviews.

A list of core outcomes was agreed. After the stakeholders’ meet-

ing, this list of core outcomes was emailed for further considera-

tion by stakeholders and authors of individual reviews. Individual

evaluations were examined and we compiled the final list of core

outcomes.



Description of the condition

The pain experienced in labour is affected by the processing of mul-

tiple physiological and psychosocial factors (Lowe 2002; Simkin

2004). Perceptions of labour pain intensity vary. Very occasionally

women feel no pain in labour and give birth unexpectedly (Gaskin

2003). At the other extreme labour pain has been reported to be

the most severe pain that a woman experiences in her lifetime

(Melzack 1984).

Pain originates from different sites during labour and birth. In

the first stage of labour (defined as the period from the onset of

labour to the complete dilatation of the cervix) (NLM 1991a),

pain occurs during contractions, is visceral or cramp-like in nature,

originates in the uterus and cervix, and is produced by distension

of uterine tissues and dilation of the cervix. In the first stage,

pain is transmitted via spinal nerves T10-L1. Labour pain can be

referred to the abdominal wall, lumbosacral region, iliac crests,

gluteal areas, and thighs. The transition phase of labour refers to

the shift from the late first stage (7 cm to 10 cm cervical dilation)

to the second stage of labour (full dilation). In the second stage

of labour (defined as from full cervical dilation to the delivery of

the baby) (Black 2009), pain occurs from distension of the vagina,

perineum, and pelvic floor. In the second stage, pain is transmitted

via the pudendal nerves, entering the spinal cord via nerve roots S2-

S4. Stretching of the pelvic ligaments is the hallmark of the second

stage of labour. Second stage pain is characterised by a combination

of visceral pain from uterine contractions and cervical stretching

and somatic pain from distension of vaginal and perineal tissues.

In addition, the woman experiences rectal pressure and an urge to

’push’ and gives birth to her baby as the presenting part descends

into the pelvic outlet.

Many factors influence the physiological and psychological pro-

cesses of birth and the extent to which women experience pain,

including parity and the way labour is managed. The pattern of

pain, for instance, appears to be different in nulliparous as com-

pared with multiparous women. Typically, nulliparous women ex-

perience greater sensory pain than multiparous women during

early labour (before 5 cm dilatation) (Lowe 2002). The positions

adopted by women and the extent of their mobility during labour

may also significantly affect the perception of pain (Kibuka 2009;

Lawrence 2009). A Cochrane systematic review (Gupta 2006)

found a reduction in the reporting of severe pain during the second

stage of labour for women using any upright or lateral position as

compared with women lying on their back during labour. Women

may also experience induced labour as being more painful than

spontaneous labour (NICE 2008).

Numerous psychosocial factors also exert an influence on women’s

experience of labour pain. Prior experience of labour and child-

birth, culture and ethnicity, educational attainment and a woman’s

ability to cope are often suggested as significant mediating variables

on the experience of labour pain (Lowe 2002). In the last century,

several philosophies of pain control evolved, using strategies to

break what has been described as the fear-tension-pain cycle (Dick

Read 1954; Dick Read 2004). Grantly Dick-Read, the famous

advocate of ’natural childbirth’, suggested that fear and anxiety

can produce muscle tension, resulting in an increased perception

of pain. Strategies to break the cycle of fear-tension-pain include

being prepared through education and purposeful activity such

as relaxation and focused breathing to relieve tension (Mozingo

1978). A wide range of ’mind-body’ interventions are currently

being used during pregnancy for preventing or treating women’s

anxiety, including autogenic training, auto-suggestion, biofeed-

back, hypnosis, imagery, meditation, prayer, relaxation therapy,

tai chi and yoga (Marc 2011).

The physical and cultural birth environment and the degree of

emotional support provided by clinical carers and the woman’s

birth companions also affect perceptions of pain (Foureur 2008a;

Foureur 2008b). In their work with pregnant woman and expec-

tant fathers, childbirth educators, midwives and doulas (a woman

who assists women during labour and childbirth) adopt a range

of different approaches to the preparation for labour and birth

and ways of planning and managing labour. Leap and Anderson

introduced ’the pain relief paradigm’ and the ’working with pain

paradigm’ to theorise these different approaches (Leap 2008). The

pain relief paradigm is based on a set of beliefs including the con-

viction that labour pain is unnecessary and barbaric in the modern

world, that the benefits of analgesia outweigh the risks and women

should not be made to feel guilty if they choose pain relief (Leap

2004). The working with pain paradigm is based on the view that

pain is an important part of the physiology of normal labour and

that, given optimal support, a woman can cope with levels of pain

in normal labour using her own natural endorphins. Endorphins

are opioids produced by the body in response to pain and other

stressors. A key role for the midwife is to reduce stimulation to the

woman’s senses so as to facilitate endorphin release (Leap 2004).

Various multi-dimensional interventions have been shown to have

an impact on the perception of pain during childbirth such as

continuous support, environment and midwife-led care (Begley

2009; Hatem 2008; Hodnett 2007; Skibsted 1992). A Cochrane

review of continuous support for women during childbirth found

that women who had continuous intrapartum support were likely

to have a slightly shorter labour, were more likely to have a sponta-

neous vaginal birth and less likely to have intrapartum analgesia or

to report dissatisfaction with their childbirth experiences (Hodnett

2007). Another Cochrane systematic review found that women

who receive midwife-led continuity of care from a small number

of midwives are less likely to use pharmacological pain relief in

labour, more likely to have an intervention-free labour and birth,

and report an increased sense of control (Hatem 2008). Drawing

together published sources of evidence, a non-Cochrane overview

suggests that a trusting relationship with caregivers, continuous

support, midwife-led care, preparation for labour, a home or birth

centre setting and use of a birth pool are factors which make it

more realistic to adopt a working with pain approach (Leap 2010).

Within the scope of the Cochrane systematic overview, we are not



able to focus in detail on the many possible interactions that medi-

ate the pain experience (spontaneous labour versus induced, prim-

iparous versus multiparous, term versus preterm birth, continuous

support versus no continuous support). Instead, we will consider

these in subgroup analyses and evaluate their impact within the

discussion and conclusions of the overview. The interventions that

we will consider for the systematic overview have a primary focus

on helping women to cope with pain in labour and in relieving

pain (NICE 2007).

Description of the interventions

A wide range of pain management methods are used by women

during childbirth (Caton 2002). Commonly, these include non-

pharmacological interventions (hypnosis, biofeedback, intracu-

taneous or subcutaneous sterile water injection, immersion in

water, aromatherapy, relaxation techniques (yoga, music, audio),

acupuncture or acupressure, manual methods (massage, reflex-

ology), transcutaneous electrical nerve stimulation (TENS)) and

pharmacological interventions (inhaled analgesia, opioids, non-

opioid drugs, local anaesthetic nerve blocks, epidural and intrathe-

cal injections of local anaesthetics or opioids, or both). Broadly

speaking, the non-pharmacological interventions primarily aim to

help women cope with pain in labour, whereas the pharmacologi-

cal interventions primarily aim to relieve the pain of labour (NICE

2007). However, we acknowledge that pain in labour is multi-

faceted and that there is obviously some overlap. Also, some in-

terventions are taught in antenatal classes and administered prior

to the onset of labour (hypnosis, biofeedback, aromatherapy, re-

laxation techniques (yoga, music, audio), acupuncture or acupres-

sure, manual methods (massage, reflexology), TENS), whilst oth-

ers are administered only during labour (intracutaneous or subcu-

taneous sterile water injection, immersion in water, inhaled anal-

gesia, opioids, non-opioid drugs, local anaesthetic nerve blocks,

epidural and intrathecal injections of local anaesthetics or opioids,

or both). This issue will be explored within our discussion.

The following section outlines the range of non-pharmacological

and pharmacological interventions in current use for the manage-

ment of pain during childbirth.

Non-pharmacological interventions

1. Hypnosis

Hypnosis has been described as a state of narrow focused attention,

reduced awareness of external stimuli, and an increased response

to suggestions (Gamsa 2003). Suggestions are verbal or non-verbal

communications that result in apparent spontaneous changes in

perception, mood or behaviour. These therapeutic communica-

tions are directed to the person’s subconscious and the responses

are independent of any conscious effort or reasoning. Women can

learn self-hypnosis which can be used in labour to reduce pain

from contractions. Recent advances in neuro-imaging have led to

increased understanding of the neuro-physiological changes oc-

curring during hypnosis induced analgesia (Maquet 1999). The

anterior cingulate gyrus of the limbic system has been demon-

strated, by positron emission tomography, to be one of the sites in

the brain affected by hypnotic modulation of pain (Faymonville

2000). The suppression of neural activity, between the sensory cor-

tex and the amygdala-limbic system, appears to inhibit the emo-

tional interpretation of sensations being experienced as pain.

Hypnosis for childbirth is self-hypnosis, where a practitioner

teaches the mother how to induce a ’state of consciousness similar

to meditation which results in failure of normally perceived expe-

riences reaching conscious awareness’ (Cyna 2004). It uses focused

attention and relaxation, to develop increased receptivity to verbal

and non-verbal communications which are commonly referred to

as ’suggestions’ (August 1961; Cyna 2004; Leap 2010; Werner

1982). These are positive statements used in order to achieve spe-

cific therapeutic goals. In labour and childbirth the goal is to alle-

viate or reduce fear, tension, and pain (Eng 2006; Landolt 2011)

so that the physiological act of birth can progress in a way that

is comfortable for the mother. There is a common misconcep-

tion that when in a hypnotic state the individual loses control of

her thoughts and actions, which would jeopardise their personal

autonomy. Women using self-hypnosis for labour and birth are

fully in control and aware of what is happening to them and those

around them (August 1961).

2. Biofeedback

Biofeedback (or biological feedback) encompasses a therapeutic

technique by which individuals receive training to improve their

health and well-being through signals coming from their own

bodies (including temperature, heart rate, muscular tension). The

underlying principle is that changes in thoughts and emotions

may result in changes in body functioning. Biofeedback aims to

gain control over physiological responses with the aid of electronic

instruments, under the supervision of experts. Instruments in-

clude: electromyographs measuring muscle tension; skin temper-

ature gauges showing changes in heat emission by the skin, reflect-

ing change in blood flow; galvanic skin response sensors, which

assess the volume of sweat produced under stress by measuring

skin conductivity; electroencephalographs which measure brain-

wave activity; electrocardiographs which monitor heart rate and

rhythm and may be useful in detecting and relieving tachycardia

(an overly rapid heartbeat) and, in turn, controlling high blood

pressure. Respiration feedback devices concentrate on the rate,

rhythm, and type of breathing to help lessen symptoms of asthma,

anxiety, and hyperventilation, and also promote relaxation (AMA

1993; Rosenfeld 1996).



3. Intracutaneous or subcutaneous sterile water injection

Intracutaneous or intradermal injections of sterile water in the

skin over the sacrum have been shown to relieve the pain of labour

(Ader 1990; Trolle 1991; Wiruchpongsanon 2006). This tech-

nique could be of particular use to those practising in hospitals

that do not have access to epidural analgesia. It could also be

helpful for women who want to avoid medication during labour

and birth. The technique is thought to work through the release

of endogenous opioids (the endorphins and encephalins) and is

based on gate control pain theories (Lytzen 1989; Trolle 1991;

Wiruchpongsanon 2006).

4. Immersion in water

Warm water immersion during labour, including birth, used for

relaxation and pain relief, has a long history in lay and clinical care

(Garland 2000). It refers to the immersion in water by a pregnant

woman during any stage of labour (first, second, third), and where

the woman’s abdomen is completely submerged. The immersion

takes place in a receptacle that may be a pool, tub or bath, and

which is larger than a normal domestic bath. Immersion may be

for one or more stages of labour, and for any duration. The buoy-

ancy of water enables a woman to move more easily than on land

(Edlich 1987). This can facilitate the neuro-hormonal interactions

of labour, alleviating pain, and potentially optimising the progress

of labour (Ginesi 1998a; Ginesi 1998b). Water immersion may be

associated with improved uterine perfusion, less painful contrac-

tions, and a shorter labour with fewer interventions (Aird 1997;

Garland 2000; Geissbuehler 2000; Moneta 2001; Otigbah 2000;

Schorn 1993). Also, shoulder-deep warm water immersion reduces

blood pressure due to vasodilatation of the peripheral vessels and

redistribution of blood flow. It is suggested that water immersion

during labour increases maternal satisfaction and sense of control

(Hall 1998; Richmond 2003). It is also suggested that the fetus

benefits from a relaxed mother, as this optimises placental perfu-

sion, and release of ’nature’s opiates’, the endogenous opioids (en-

dorphins and encephalins). Accordingly, when the mother is not

fearful, oxytocin release is optimised, stimulating effective con-

tractions. In addition, the ease of mobility that water immersion

offers may optimise fetal position by encouraging flexion (Ohlsson

2001).

5. Aromatherapy

Aromatherapy is the use of essential oils, drawing on the healing

powers of plants. The mechanism of action for aromatherapy is

unclear. Studies investigating psychological and physiological ef-

fects of essential oils showed no change on physiological parame-

ters such as blood pressure or heart rate but did indicate psycho-

logical improvement in mood and anxiety (Stevensen 1995). Es-

sential oils are thought to increase the secretion of the body’s own

sedative, stimulant and relaxing neurotransmitters (paracrine and

endocrine). The oils may be massaged into the skin, or inhaled by

using a steam infusion or burner. Aromatherapy is increasing in

popularity among midwives and nurses (Allaire 2000).

6. Relaxation techniques (yoga, music, audio)

Relaxation techniques are mind-body interventions which are

based on developing conscious awareness of muscular tension, the

practice of releasing tension and maintaining relaxation often car-

ried out in conjunction with focused breathing, meditation and

visualisation. These kinds of approaches are commonly used for

labour. Unanswered questions include: which approaches are most

effective, the most appropriate timing for preparatory interven-

tions during pregnancy, the extent to which practice makes a dif-

ference and which techniques women find acceptable and useful.

Yoga, meditation, music and hypnosis techniques may all have a

calming effect and provide a distraction from pain and tension

(Vickers 1999). In future updates, this review will be split into

separate reviews on yoga, music and audio.

7. Acupuncture or acupressure

Acupuncture involves the insertion of fine needles into different,

specific parts of the body. Other acupuncture-related techniques

include laser acupuncture and acupressure (applying pressure on

the acupuncture point). These techniques all aim to treat illnesses

and soothe pain by stimulating acupuncture points. Acupuncture

points used to reduce labour pain are located on the hands, feet

and ears. Several theories have been presented as to exactly how

acupuncture works. One theory proposes that stimulation of touch

fibres blocks pain impulses at the ‘pain gates’ in the spinal cord.

The impulses in the pain fibres are thus less likely to reach the

brain stem, thalamus and cerebral cortex (Wall 1967). Since most

acupuncture points are either connected to, or located near, neural

structures, this suggests that acupuncture stimulates the nervous

system. Another theory suggests that acupuncture stimulates the

body to release endorphins (endogenous opioids), which reduce

pain (Pomeranz 1989).

8. Massage, reflexology and other manual methods

Manual healing methods include massage and reflexology. Massage

involves manipulation of the body’s soft tissues. It is commonly

used to help relax tense muscles and to soothe and calm the indi-

vidual. A woman who is experiencing backache during labour may

find massage over the lumbosacral area soothing. Some women

find light abdominal massage, known as ’effleurage’, comforting.

Different massage techniques may suit different women. Massage

may help to relieve pain by assisting with relaxation, inhibiting

sensory transmission in the pain pathways or by improving blood

flow and oxygenation of tissues (Vickers 1999). Reflexologists pro-

pose that there are reflex points on the feet corresponding to or-

gans and structures of the body and that pain may be reduced by



gentle manipulation or pressing certain parts of the foot. Pressure

applied to the feet has been shown to result in an anaesthetising

effect on other parts of the body (Ernst 1997). In future updates,

this review will be split into separate reviews on massage and re-

flexology.

9. TENS

Transcutaneous electrical nerve stimulation (TENS) uses a de-

vice which emits low voltage electrical impulses which vary in fre-

quency and intensity. In labour, the electrodes from the TENS ma-

chine are usually attached to the lower back and women themselves

control the electrical currents using a hand-held device. TENS can

also be applied to acupuncture points or directly to the head by

trained staff. The way that TENS acts to relieve pain is not well

understood. The electrical pulses are thought to stimulate nerve

pathways in the spinal cord which block the transmission of pain.

A number of theories have been proposed. According to the gate

control theory (Melzack 1965), the transmission of pain is inhib-

ited by the stimulation of large, afferent or sensory touch nerve

fibres which carry impulses towards the central nervous system. It

is also suggested that painful stimuli result in release of endorphins

and encephalins, which mediate the experience of pain (Lechner

1991). It is further thought that by reducing anxiety, increasing

a sense of control, and by providing distraction, TENS increases

a woman’s sense of well-being and thereby reduces pain in labour

(Brucker 1984; Findley 1999; Gentz 2001; Simkin 2004). Lastly,

TENS may reduce the length of labour by suppressing the release

of catecholamines, which can inhibit the contraction of the uterus

and thereby, delay progress (Lowe 2002).

Pharmacological interventions

1. Inhaled analgesia

Inhaled analgesia during labour involves the inhalation of sub-

anaesthetic concentrations of anaesthetic agents while the mother

remains awake and her protective laryngeal reflexes remain in-

tact. Possibilities for inhaled analgesia for pain relief in labour in-

clude isoflurane, sevoflurane, trichloroethylene in air, methoxyflu-

rane, cyclopropane, nitrogen protoxide, nitralgin, anesoxyn and

eutonal. Subanaesthetic concentrations of nitrous oxide, enflu-

rane, isoflurane and methoxyflurane do not significantly decrease

uterine contractions and are preferred for this reason. However,

only nitrous oxide (in 50% oxygen) is widely used for analgesia

in modern obstetric practice. This is attributed to: ease of admin-

istration, relative lack of flammability, absence of pungent odour,

absence of effect on uterine contractions, lack of reports of ma-

lignant hyperthermia, minimal toxicity and minimal depression

of the cardio-vascular system; a favourable partition coefficient

leading to rapid onset and elimination from woman, fetus and

neonate (KNOV 2009; Rosen 2002). The evidence on the use

of nitrous oxide for relief of labour pain has been summarised in

a systematic review (Rosen 2002). The woman can self-admin-

ister under supervision, after initial instruction (Clyburn 1993).

Inhaled analgesia is administered either intermittently, with dis-

continuation of use as the contraction pain eases or disappears

(recommended), or continuously, by inhaling both during and be-

tween contractions. However, there is concern, centring on staff

rather than patients, regarding the effect of prolonged exposure,

because of reported possible associations with loss of fertility, mis-

carriage, preterm birth and lowered concentrations of vitamin B12

(Ahlborg 1996; Axelsson 1996; BOC 2010; Bodin 1999; Boivin

1997; Zielhuis 1999). Accordingly, nitrous oxide concentrations

should be regularly measured, according to manufacturers’ guide-

lines (BOC 2010). Other possible adverse effects are maternal

drowsiness, hallucinations, vomiting, hyperventilation and tetany,

and maternal or fetal hypoxia usually encountered when nitrous

oxide use is excessively prolonged or extensive, especially if the rule

of self-administration is violated.

The precise mechanism of action of inhaled analgesia remains un-

certain, but anaesthetic actions are related to suppression of activ-

ity of the reticuloendothelial network in the brainstem. Maze and

Fuginaga hypothesised that nitrous oxide induces the release of

endogenous opioids in the peri-aqueductual grey area of the mid-

brain (Maze 2000), which could modulate pain stimuli through

the descending spinal cord nerve pathways.

2. Opioids

Most obstetric units in developed countries offer intramuscular

opioids, along with facilities for epidural analgesia. Opioids are

relatively inexpensive drugs, and the use of pethidine, meptazinol

or diamorphine during labour is common midwifery and obstet-

ric practice in some countries. In other parts of the world, par-

enteral (intravenous or intramuscular) opioids commonly used in

labour include morphine, nalbuphine, fentanyl and more recently

remifentanil (Evron 2007). The extent of usage of parenteral opi-

oids during labour worldwide is unclear. Worldwide, pethidine is

the most commonly used opioid (Bricker 2002). There are con-

cerns about maternal effects which include an impaired capacity

to engage in decision making about care, sedation, hypoventila-

tion, hypotension, prolonged labour, urine retention, nausea and/

or vomiting, and the slowing of gastric emptying, which increases

the risk of inhalation of gastric contents should a general anaes-

thetic be required in an emergency. If a woman feels drowsy or

sedated, she is less likely to mobilise and adopt an upright position

and, as a result, this may lengthen her labour and make it more

painful (Lawrence 2009). Opioids readily cross the placenta by

passive diffusion, and some are trapped by ionisation. Neonatal

respiratory depression and hypothermia remain major concerns.

It is estimated that it can take a newborn three to six days to elim-

inate pethidine, and its metabolite, norpethidine, from its system

(Hogg 1977). Pethidine has been shown to significantly affect fe-



tal heart rate variability, accelerations and decelerations, during

labour (Sekhavat 2009; Solt 2002). Changes in normal fetal heart

indices have consequences for the woman. She will be required

to have electronic fetal heart rate monitoring if she is in hospital,

and transfer to hospital if she is in the community. Results from

observational studies have reported effects of opioids on the new-

born that include inhibited suckling at the breast and decreased

alertness, resulting in delayed effective breastfeeding (Nissen 1995;

Ransjo-Arvidson 2001; Righard 1990) and earlier cessation (Rajan

1994).

3. Non-opioid drugs

Non-opioid medications are drugs that have principally analgesic,

antipyretic, sedative and anti-inflammatory actions. They are not

technically part of the analgesic family, but are nonetheless consid-

ered analgesics in practice. These include acetaminophen (parac-

etamol), the non-steroidal anti-inflammatory drugs (NSAIDs),

such as aspirin, and antispasmodic drugs such as hyoscine

(Bayarski 2006; Hebbes 2000).

Acetaminophen and NSAIDs can effectively relieve mild to mod-

erate pain, and for moderate to severe pain, they can be used in

combination with other drugs to enhance pain relief.

Non-opioids affect some of the chemical changes that normally

take place wherever body tissues are injured or damaged. These

chemical changes at the site of the injury typically result in inflam-

mation and increased pain sensitivity. However, there are limits to

the pain afforded by non-opioids; this is referred to as a ’ceiling

effect’. Once that upper limit or ceiling is reached, taking more

of the non-opioid will not provide any further pain relief. Most

non-opioids are quite safe when used for temporary acute pain;

problems may arise when people take them over a long period of

time (for chronic pain), then they could damage the lining of the

gastro-intestinal tract or the kidneys, or, more rarely, other organs

(Bayarski 2006; Dewhurst 2007; Hebbes 2000).

4. Local anaesthetic nerve blocks

Pudendal and paracervical block (PCB) are the most commonly

performed local anaesthetic nerve blocks which have been used

for decades.

A pudendal block is performed by injection of local anaesthetic

around the trunk of the pudendal nerve. Pudendal block is used

in the second stage of labour, predominantly when instrumental

delivery is performed (Pace 2004). During descent of the present-

ing part of the fetus in the second stage, the primary focus of pain

is in the lower vagina, perineum and vulva, which are innervated

from sacral nerve roots 2, 3 and 4 via the pudendal nerve. Infiltra-

tion of local anaesthetic around the trunk of the pudendal nerve

at the level of ischial spines leads to analgesia of these areas. Prior

to the widespread use of epidural analgesia in obstetrics, pudendal

blocks were the preferred analgesic technique for delivery. Puden-

dal blocks are also used to supplement epidural labour analgesia,

which occasionally may have some ’sacral sparing.’

A paracervical block is performed by infiltration of local anaes-

thetic in the cervix. It is injected into between two to six sites at a

depth of 3 mm to 7 mm alongside the vaginal portion of the cervix

in the vaginal fornices (Mankowski 2009). Paracervical infiltration

interrupts the visceral sensory fibres of the lower uterus, cervix,

and upper vagina (T10-L1) as they pass through the uterovaginal

plexus (Frankenhauser’s plexus) on each side of the cervix.

5. Epidural (including combined spinal epidural)

Epidural analgesia is a central nerve blockade technique, which

involves the injection of a local anaesthetic, with or without an

opioid into the lower region of the spine close to the nerves that

transmit painful stimuli from the contracting uterus and birth

canal. The most commonly prescribed local anaesthetic in the

UK is bupivacaine; levobupivacaine, ropivacaine, and lidocaine/

lignocaine are also used in epidural or intrathecal injections. Local

anaesthetics inhibit nerve conduction by blocking sodium chan-

nels in nerve cell membranes, thereby preventing the propagation

of nerve impulses along these fibres. Blocking impulses from the

sensory nerves as they cross the epidural space results in analge-

sia, which should be apparent within 10 to 20 minutes of ad-

ministration. The anaesthetic placed in the epidural space exerts

a concentration specific effect, affecting all the modalities of sen-

sation of the blocked nerves to varying degrees, such that admin-

istration of a lower-dose anaesthetic (e.g. 0.125% bupivacaine)

partially selectively blocks painful stimuli while preserving motor

function, whereas higher doses of anaesthetic cause complete sen-

sory and motor blockade, limiting mobility in labour. The sec-

ond stage of labour may be prolonged and instrumental delivery is

more likely (Anim-Somuah 2005). Blocking of sympathetic nerves

occurs at varying concentrations and manifests as vasodilatation

and hypotension (Anim-Somuah 2005). Other reported problems

include: urine retention, shivering, fever, tinnitus, tremor, respi-

ratory and cardiovascular depression. Epidural solutions are ad-

ministered either by bolus, continuous infusion or patient-con-

trolled pump. An intermittent technique involves injections of lo-

cal anaesthetic through a catheter positioned in the epidural space.

Boluses of higher concentrations, as used in the earlier years, have

been associated with a dense motor block resulting in reduced mo-

bility, decreased pelvic tone and impairment of the bearing down

effort in the second stage of labour (Thornton 2001). More re-

cently, there has been a trend to use a lower concentration of local

anaesthetic in combination with a variety of opiates; these com-

binations provide analgesic effect while allowing the woman to

maintain some motor function, such as the ability to move during

her labour and retain her ability to bear down (COMET 2001;

Russell 2000). Combined spinal-epidural (CSE) involves a single

injection of local anaesthetic or opiate, or both, into the cerebral

spinal fluid as well as insertion of the epidural catheter. CSE com-



bines the advantages of spinal analgesia (faster onset of pain relief,

more reliable analgesia) with the advantages of epidural analgesia

such as continuing pain relief, potentially maintained throughout

the entire duration of labour (Hughes 2003). However, some of

the disadvantages of opioid administration remain, including itch-

ing, respiratory depression and, in observational studies, reduced

breastfeeding rates (Jordan 2005; Torvaldsen 2006), but evidence

is uncertain (Reynolds 2011). In addition, the rare but serious

adverse effects of neuraxial administration should be considered,

including introduction of infection, nerve root damage and even

inadvertent intravenous injection (Jordan 2010).

Why it is important to do this overview

The totality of evidence from randomised controlled trials of in-

terventions for pain management in labour has never been assem-

bled before in a systematic and comprehensive way. An ’overview

of reviews’ will provide a clinically meaningful summary of one

of the most important topics in pregnancy and childbirth. The

overview provides a coherent summary of the totality of evidence

without the need to access many individual systematic reviews.

This may help busy clinicians, policy makers, childbirth educators

and consumers.

O B J E C T I V E S

The objectives of this overview are to summarise the evidence

from Cochrane systematic reviews regarding the effects and sa-

fety of non-pharmacological and pharmacological interventions

to manage pain in labour. We also considered findings from

non-Cochrane systematic reviews in the absence of an available

Cochrane review.

M E T H O D S

Criteria for considering reviews for inclusion

In this overview we have included any published Cochrane system-

atic review of randomised controlled trials focusing on the man-

agement of pain in labour. We have only included non-Cochrane

systematic reviews in the absence of an available Cochrane review

in an area listed below. To be considered, the non-Cochrane sys-

tematic review must have used a systematic approach, only in-

cluded randomised controlled trials and have assessed the method-

ological quality of the included clinical trials.

The participants in reviews are women in labour. This includes

women in high-risk groups, e.g. preterm labour or following in-

duction of labour.

We have included the following non-pharmacological (hypno-

sis, biofeedback, intracutaneous or subcutaneous sterile water in-

jection, immersion in water, aromatherapy, relaxation techniques

(yoga, music, audio), acupuncture or acupressure, manual meth-

ods (massage, reflexology), transcutaneous electrical nerve stimu-

lation (TENS)) and pharmacological interventions (inhaled anal-

gesia, opioids, non-opioid drugs, local anaesthetic nerve blocks,

epidural and intrathecal injections of local anaesthetics or opioids,

or both).

We have compared interventions with placebo/no treatment or

with a different intervention.

Each of the contributing Cochrane reviews followed a generic pro-

tocol (Jones 2011). To avoid duplication, each Cochrane review

included comparisons only with the interventions listed above it in

the following list of potential interventions. Thus, the aromather-

apy review (6), from the available evidence, only included com-

parisons with immersion in water (5), sterile water injection (4),

biofeedback (3), hypnosis (2) and placebo/no treatment (1). This

strategy aimed to avoid the same comparisons being included in

more than one of the original Cochrane reviews. Methods of pain

management identified in the future will be added to the end of

the list. The current list is as follows.

1. Placebo/no treatment.

2. Hypnosis (Madden 2012)

3. Biofeedback (Barragán 2011).

4. Intracutaneous or subcutaneous sterile water injection

(Derry 2012).

5. Immersion in water (Cluett 2009).

6. Aromatherapy (Smith 2011c).

7. Relaxation techniques (yoga, music, audio)* (Smith 2011b).

8. Acupuncture or acupressure (Smith 2011a).

9. Massage, reflexology and other manual methods* (Smith

2012).

10. TENS (Dowswell 2009).

11. Inhaled analgesia (Klomp 2012).

12. Opioids (Ullman 2010).

13. Non-opioid drugs (Othman 2012).

14. Local anaesthetic nerve blocks (Novikova 2012).

15. Epidural (including combined spinal epidural)

(Anim-Somuah 2011; Simmons 2012).

* In future updates these individual reviews will be split into sep-

arate reviews on yoga, music, audio and massage and reflexology,

respectively.

Outcomes

Types of outcome measure

The following list of core outcomes was developed in collaboration

with members of the Pregnancy and Childbirth Group (PCG)

consumers’ group - see ’History’ described in Background.



Primary outcomes

Effects of interventions

Pain intensity (as defined by trialists)

Satisfaction with pain relief (as defined by trialists)

Sense of control in labour (as defined by trialists)

Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

Effect (negative) on mother/baby interaction

Breastfeeding (at specified time points)

Assisted vaginal birth

Caesarean section

Adverse effects (for women and infants; review specific)

Admission to special care baby unit/neonatal intensive care unit

(as defined by trialists)

Apgar score less than seven at five minutes

Poor infant outcomes at long-term follow-up (as defined by trial-

ists)

Other outcomes

Cost (as defined by trialists)

Measuring any subjective outcome is a major challenge. Pain is a

highly subjective phenomenon, with a complex physiological and

psychological basis (Kane 2002). It has been defined as “a complex

constellation of unpleasant sensory, perceptual and emotional ex-

periences and certain associated autonomic, psychological, emo-

tional and behavioural responses” (Bonica 1990). Due to this com-

plexity, there has been little research focused on developing psy-

chometrically sound measures of pain, especially in labour and

childbirth (Lowe 2002). Consequently there is considerable varia-

tion in the way that pain is measured across individual studies con-

tained within individual reviews (Bricker 2002; Dowswell 2009).

It is for these reasons that we have used the trialists’ definitions of

outcome measures from the individual reviews. Similarly, breast-

feeding as an outcome measure is not straightforward in terms of

timing of recording and reporting. The infant feeding literature

offers little consistency regarding the timing of data collection.

Consequently, it is difficult to compare data sets (Britton 2007).

In addition, definitions of exclusive, full and partial breastfeeding

will need to be considered. Where information on pain and infant

feeding has been collected, we have detailed any definitions used

in the results by individual review tables, in Additional tables.

Search methods for identification of reviews

We contacted the Trials Search Co-ordinator of the Cochrane

Pregnancy and Childbirth Group in order to identify all relevant

systematic reviews of pain management in labour. In the absence

of an available Cochrane systematic review in one of the follow-

ing areas (hypnosis, biofeedback, intracutaneous or subcutaneous

sterile water injection, immersion in water, aromatherapy, relax-

ation techniques (yoga, music, audio), acupuncture or acupres-

sure, manual methods (massage, reflexology), TENS, inhaled anal-

gesia, opioids, non-opioids, local anaesthetic nerve blocks, epidu-

ral), we searched the Database of Abstracts of Reviews of Effects

(The Cochrane Library 2011, Issue 2 of 4), MEDLINE (1966 to

31 May 2011) and EMBASE (1980 to 31 May 2011) using the

search strategies detailed in Appendix 1.

Data collection and analysis

The methodology for data collection and analysis is based on

Chapter 22 of the Cochrane Handbook of Systematic Reviews of In-terventions (Higgins 2011).

Selection of reviews

Two review authors independently assessed for inclusion all the

potential systematic reviews we identified as a result of the search

strategy. We resolved any disagreement through discussion or, if

required, we consulted a third person.

Data extraction and management

Two review authors independently extracted data from the reviews

using a predefined data extraction form. We resolved discrepancies

through discussion or, if required, we consulted a third person.

We entered data into Review Manager software (RevMan 2011)

and checked for accuracy. If any information from the reviews

was unclear or missing, we accessed the published reports of the

individual trials. If the information could not be obtained from

the published reports, then we contacted the review authors or

authors of the original reports to provide clarification and further

details.

Assessment of methodological quality of included

reviews

We have addressed two different quality assessments in this

overview: the quality of evidence in the included reviews and the

methodological quality of the systematic reviews. Two review au-

thors assessed methodological quality independently. We resolved

discrepancies through discussion or, if required, we consulted a

third person.

Quality of evidence in included reviews

Two review authors independently assessed the overall quality of

the evidence presented in the included reviews by examining the

methods used for assessing risk of bias of the individual included



studies. We assessed whether the Cochrane reviews used the do-

main-based evaluation for assessment of risk of bias as outlined in

Chapter 8 of the Cochrane Handbook for Systematic Reviews of In-terventions (Higgins 2011). For non-Cochrane systematic reviews,

we have summarised the methods used to assess methodological

quality, including details regarding the tools used and the dimen-

sions assessed e.g. sequence generation; allocation sequence con-

cealment; blinding; incomplete outcome data.

Quality of included reviews

Two review authors independently assessed the methodological

quality of the included reviews using the ’assessment of multiple

systematic reviews’ (AMSTAR) measurement tool (Shea 2007).

The AMSTAR tool assesses the following criteria.

1. Was an ’a priori’ design provided?

2. Was there duplicate study selection and data extraction?

3. Was a comprehensive literature search performed?

4. Was the status of publication (i.e. grey literature) used as an

inclusion criterion?

5. Was a list of studies (included and excluded) provided?

6. Were the characteristics of the included studies provided?

7. Was the scientific quality of the included studies assessed

and documented?

8. Was the scientific quality of the included studies used

appropriately in formulating conclusions?

9. Were the methods used to combine the findings of studies

appropriate?

10. Was the likelihood of publication bias assessed?

11. Was the conflict of interest stated?

Data synthesis

We have provided a narrative summary of the results for the in-

dividual reviews for each of the primary outcomes and present

these using tables and figures (e.g. characteristics of included re-

views, summary of quality of evidence within individual system-

atic reviews, AMSTAR ratings for each systematic review, results

by individual review tables). It was not anticipated that we would

be able to perform any quantitative data analyses. However, for

future updates of this overview, if the data allow, we may perform

some indirect comparisons of interventions across reviews for the

primary outcomes. We had planned, if possible, to present data

from the following subgroups (if these data were available within

the included systematic reviews).

1. Spontaneous labour versus induced labour.

2. Primiparous versus multiparous.

3. Term versus preterm birth.

4. Continuous support in labour versus no continuous

support.

R E S U L T S

Cochrane systematic reviews

A total of 15 Cochrane systematic reviews were identified by

the Trials Search Co-ordinator of the Cochrane Pregnancy and

Childbirth Group, all of which met the inclusion criteria for this

overview. A priori, the research question and inclusion criteria were

provided in a published generic protocol (Jones 2011). All but

one of the 15 Cochrane systematic reviews (protocols and updates

of reviews), followed this generic protocol. The Cochrane review

on combined spinal-epidural versus epidural analgesia in labour

(Simmons 2012) did not adhere to the generic protocol because

it did not fit in with the hierarchy of interventions.

Non-Cochrane systematic reviews

In order to identify any gaps not already covered by the Cochrane

systematic reviews, we searched The Database of Abstracts of Re-

views of Effects (The Cochrane Library 2011, Issue 2 of 4), MED-

LINE (1966 to 31 May 2011) and EMBASE (1980 to 31 May

2011) using the search strategies detailed in Appendix 1. A total

of 65 potentially eligible reviews were identified from this search.

Three of these filled a gap not already covered by the Cochrane

reviews (Halpern 2003a; Hutton 2009; Mardirosoff 2002). The

remaining 62 were excluded because they were not a systematic

review (N = 26), they were out of date and focused on an area al-

ready covered by one of the included Cochrane or non-Cochrane

systematic reviews (N = 32), or they did not fit the inclusion cri-

teria for this overview (N = 4). A description of the characteristics

of these excluded reviews, and the reasons for exclusion are set out

in an additional table (Table 1).

Figure 1 gives a flow diagram outlining the selection process and

review numbers at each stage.



Figure 1. Study flow diagram.



Description of included reviews

We have included 15 Cochrane reviews: nine non-pharmaco-

logical reviews (hypnosis (Madden 2012), biofeedback (Barragán

2011), intracutaneous or subcutaneous sterile water injection

(Derry 2012), immersion in water (Cluett 2009), aromatherapy

(Smith 2011c), relaxation techniques [yoga, music, audio] (Smith

2011b), acupuncture or acupressure (Smith 2011a), manual meth-

ods (massage, reflexology) (Smith 2012), transcutaneous electri-

cal nerve stimulation (TENS) (Dowswell 2009)) and six exam-

ining pharmacological interventions (inhaled analgesia (Klomp

2012), opioids (Ullman 2010), non-opioid drugs (Othman 2012),

local anaesthetic nerve blocks (Novikova 2012), epidural and

intrathecal injections of local anaesthetics or opioids, or both

(Anim-Somuah 2011; Simmons 2012)). All of these reviews have

recently been updated and the search dates are in 2011. Eleven of

the reviews had already been published or were in-press at the time

this overview was prepared. However, while four of the remaining

reviews had been submitted for publication at this time, they had

not been revised after peer review, or approved for publication.

Therefore, the findings we have reported in this overview for these

reviews (examining hypnosis (Madden 2012), inhaled analgesia

(Klomp 2012), non-opioid drugs (Othman 2012) and combined

spinal epidural (Simmons 2012)) are based on the draft reviews

submitted by the authors for editorial consideration. We are aware

that including data from these non-completed reviews potentially

introduces bias into the overview process. If there are changes in

results in of any of these reviews, new findings will be incorporated

into the first update of this overview.

The titles of the 15 Cochrane reviews are listed below:

1. Hypnosis for pain management during labour and childbirth

(Madden 2012).

2. Biofeedback for pain management during labour (Barragán

2011).

3. Intracutaneous or subcutaneous sterile water injection for pain

management in labour (Derry 2012).

4. Immersion in water in labour and birth Cluett 2009).

5, Aromatherapy for pain management in labour (Smith 2011c).

6. Relaxation techniques for pain management in labour (Smith

2011b).

7. Acupuncture or acupressure for pain management in labour

(Smith 2011a).

8. Massage, reflexology and other manual methods for pain man-

agement in labour (Smith 2012).

9. Transcutaneous electrical nerve stimulation (TENS) for pain

management in labour (Dowswell 2009).

10. Inhaled analgesia for pain management in labour (Klomp

2012).

11. Parenteral opioids for maternal pain management in labour

(Ullman 2010).

12. Non-opioid drugs for pain management in labour (Othman

2012).

13. Local anaesthetic nerve block for pain management in labour

(Novikova 2012).

14. Epidural versus non-epidural or no analgesia in labour (Anim-

Somuah 2011).

15. Combined spinal-epidural versus epidural analgesia in labour

(Simmons 2012).

In addition we have included three non-Cochrane reviews that

focused on methods of pain relief or comparisons not covered by

the Cochrane reviews (Halpern 2003a; Hutton 2009; Mardirosoff

2002) and the dates of publication indicate that these reviews are

less up to date. These reviews examined sterile water injections

(Hutton 2009); intrathecal opioids (Mardirosoff 2002) and epidu-

ral ropivacaine versus bupivacaine (Halpern 2003a), as listed:

1. Sterile water injection for labour pain: a systematic review and

meta-analysis of randomised controlled trials (Hutton 2009).

2. Fetal bradycardia due to intrathecal opioids for labour analgesia:

a systematic review (Mardirosoff 2002).

3. Epidural ropivacaine versus bupivacaine for labor: a meta-anal-

ysis (Halpern 2003a).

The specific inclusion and exclusion criteria in the contributing

reviews varied: all focused on pain in labour and all included ran-

domised trials; however, authors of each review had particular cri-

teria for participants and interventions. For example, in the hyp-

nosis review women may have been recruited and the interven-

tion may have occurred during pregnancy (for example in ante-

natal classes), whereas, for pharmacological interventions women

were predominantly recruited when they were admitted to hospi-

tal during labour. While all but one (combined spinal epidural)

of the Cochrane reviews were based on a generic protocol and

collected outcome data on a prespecified list of primary and sec-

ondary outcomes, individual review authors may also have col-

lected data on other outcomes which we have not reported in this

overview. Outcomes relating to adverse effects are mainly review

(i.e. intervention) specific. For non-Cochrane reviews outcomes

were determined by the individual review authors and may not

have included most of our prespecified outcomes; for this reason

we have reported only limited data from these non-Cochrane re-

views.

The number of trials and participants included in the various

contributing reviews varied considerably from two studies and

535 women in the aromatherapy review, and four studies and 201

women in the biofeedback review, through to 57 included studies

and more than 7000 participants in the parenteral opioids review.

The trials in each of the contributing reviews were carried out in

a variety of settings and over varying periods of time; for example,

epidural has been used widely since the 1980s whereas studies

included in the parenteral opioids review date back as far as the



1930s.

We have set out the characteristics of the contributing reviews in

four additional tables and it is important that the findings of the

overview are interpreted in the light of information in the tables.

Characteristics of included Cochrane systematic reviews - non-

pharmacological interventions - see Table 2

Characteristics of included Cochrane systematic reviews - phar-

macological interventions - see Table 3

Characteristics of included Non-Cochrane systematic reviews -

non-pharmacological interventions - see Table 4

Characteristics of included Non-Cochrane systematic reviews -


Quality of evidence in included reviews

The quality of the evidence (i.e. the methodological quality of in-

dividual trials) in each of the contributing reviews was assessed us-

ing the Cochrane risk of bias tool set out in the Handbook (Higgins

2011). Just as the number of trials contributing data to each re-

view varied, so too did the overall methodological quality of those

trials. Again, the evidence in each section of the results should be

interpreted in the light of the strengths and weaknesses of indi-

vidual trials. In the Cochrane reviews focusing on non-pharmaco-

logical interventions, for example, blinding staff and participants

in trials was either not attempted, or it was not clear that alterna-

tives (such as sham TENS devices) achieved successful blinding.

In the Cochrane review focusing on sterile water injection trials

were only included if they were double-blind, but this criterion

was not used in all reviews. Many trials included in reviews used

methods to generate the randomisation sequence, and to allocate

participants to groups, with high risk of bias. For example, in the

TENS review, most of the included studies used methods of allo-

cating participants that did not conceal allocations and therefore

were at high risk of bias. Many trials involving pharmacological

methods could achieve blinding through use of placebo, but these

trials often encountered other methodological problems (for ex-

ample high levels of sample attrition or protocol deviations) leav-

ing results at high risk of bias. The quality of the evidence from

Cochrane reviews has been summarised in two additional tables:

Quality of evidence in included Cochrane systematic reviews -

non-pharmacological interventions - see Table 6

Quality of evidence in included Cochrane systematic reviews -


The same issues regarding the strengths and weaknesses of the

evidence in non-Cochrane reviews apply. However, as these reviews

did not use the Cochrane domain based risk of bias tool we were

unable to assess the overall quality of contributing studies. The

quality of evidence in the three non-Cochrane review are set out

in additional tables:

Quality of evidence in included Non-Cochrane systematic reviews

- non-pharmacological interventions - see Table 8.

Quality of evidence in included Non-Cochrane systematic reviews

- pharmacological interventions - see Table 9

Methodological quality of included reviews

The methods used in Cochrane reviews were assessed using the

AMSTAR rating scale described above. As all Cochrane reviews

followed a generic protocol specifying methods, scores were high

for all reviews. The Cochrane Handbook for Systematic Reviews ofInterventions specifies that the search should be comprehensive;

data extraction should be carried out independently by two peo-

ple; methods for data synthesis should be specified; reasons for

excluding studies and characteristics of those included should be

described; the quality of included studies should be assessed; and

data should be analysed and findings reported appropriately. These

are all factors which were adhered to in all contributing Cochrane

reviews and which contribute to achieving positive AMSTAR rat-

ings. In addition, all review protocols go through a peer review pro-

cess before publication when methodological quality is assessed.

So, it was not surprising that all these reviews received high-quality

ratings. For the non-Cochrane reviews scores were less high; this

was generally because some aspects of the review process may not

have been explicit in the published reviews. Findings regarding

the quality of contributing reviews are set out in three additional

tables.

AMSTAR ratings for each Cochrane systematic review - non-phar-

macological interventions - see Table 10

AMSTAR ratings for each Cochrane systematic review - pharma-

cological interventions - see Table 11

AMSTAR ratings for each Non-Cochrane systematic review - see

Table 12

Effect of interventions

For all interventions, where separate data were available, we have

set out the results under three major comparison groups:

1. Intervention versus placebo or standard care;

2. different forms of the same intervention (e.g. one opioid

versus another opioid); and,

3. one type of intervention versus a different type of

intervention (e.g. TENS versus opioid), see Figure 2.



Figure 2. Summary of comparisons within included reviews

Not all contributing reviews included results for all three types

of comparisons. Most reviews compared the intervention with

placebo or no treatment. However, with the exceptions of par-

enteral opioids and different types of epidural, there were few di-

rect comparisons between different forms of the same interven-

tion, and even fewer instances of different interventions being

compared with each other, see Figure 2.

For each review, we have set out the overall number of studies and

total number of women randomised. We have also provided the

number of studies and numbers of women randomised to each

different comparison. These two sets of numbers may differ, as

some trials included more than two arms and may be included in

more than one comparison. We have also specified the number of

studies and women at the outcome level: for many outcomes only

a small number of studies contributed data.

Cochrane Systematic reviews

Non-pharmacological interventions (nine reviews)

1. Hypnosis for pain management during labour and

childbirth (seven studies)

Seven studies randomising 1213 women were included in this

review (Madden 2012): one of the included studies included three

arms (hypnosis versus another type of hypnosis versus standard

care, 448 women) and data from the hypnosis versus standard care

arms are included in comparison 1.1. and data from the hypnosis

versus different hypnosis arm has been included in comparison

1.2.

1.1. Hypnosis versus no hypnosis/ standard care (seven

studies, 1070 women)

For this comparison control group interventions varied, and it

was not always clear whether the experimental intervention was

offered as an addition, or as an alternative to routine childbirth

preparation. There were some studies that did not contribute data

to any outcomes.

There was no evidence of a significant difference in satisfaction

with pain relief (risk ratio (RR) 1.06, 95% confidence interval

(CI) 0.94 to 1.20, one trial, 264 women); satisfaction with child-

birth experience (RR 1.36, 95% CI 0.52 to 3.59, two trials, 370



women); assisted vaginal birth (RR 0.73, 95% CI 0.36 to 1.50,

three trials, 414 women); caesarean section (RR 0.54, 95% CI

0.18 to 1.62, three trials, 867 women) or admission to neonatal

intensive care unit (RR 0.58, 95% CI 0.12 to 2.83, two trials, 345

women). There was no evidence of a significant difference for any

of the other outcomes analysed (breastfeeding; adverse effects for

women or infants; Apgar score less than seven at five minutes).

None of the following outcomes were analysed within the review:

sense of control in labour; effect on mother/baby interaction; poor

infant outcomes at long-term follow-up; or cost.

1.2. One type of hypnosis versus another type of hypnosis

(one study, 297 women)

When hypnosis administered by a hypnotherapist was compared

with hypnosis on an audio CD administered by a nurse without

training in hypnotherapy, there were no significant differences for

any of the outcomes analysed (satisfaction with pain relief; satis-

faction with childbirth experience; breastfeeding; assisted vaginal

birth; caesarean section; adverse effects for women and infants;

admission to neonatal intensive care unit; Apgar score less than

seven at five minutes).


sense of control in labour; effect on mother/baby interaction; poor


1.3. Hypnosis versus a different intervention

No studies are included in this comparison.

See Table 13 for all results relating to hypnosis.

2. Biofeedback for pain management during labour (four

studies)

2.1. Biofeedback versus no biofeedback/ standard care (four

studies, 201 women)

Four studies randomising 201 women were included in this re-

view (Barragán 2011): the type of biofeedback and the childbirth

preparation received by women in control arms varied in these

studies . The data relating to pain intensity, satisfaction with pain

relief, sense of control in labour or Apgar score were not reported

in a format that could be included in any analysis.

There was no significant difference between groups comparing

biofeedback with control for assisted vaginal birth (average RR

0.75, 95% CI 0.18 to 3.10, two trials, 103 women (random effects;

heterogeneity: I2 = 80%, Tau2 = 0.86, Chi2 test for heterogeneity

P = 0.02) or caesarean section (RR 0.41, 95% CI 0.14 to 1.15,

two trials, 103 women).


satisfaction with childbirth experience; effect on mother/baby in-

teraction; breastfeeding; adverse effects for women and infants;

admission to special care baby unit/neonatal intensive care unit;

poor infant outcomes at long-term follow-up; or cost.

2.2. One type of biofeedback versus a different type of

biofeedback

No studies examined this comparison.

2.1. Biofeedback versus a different intervention


See Table 14 for all results on biofeedback.

3. Intracutaneous or subcutaneous sterile water injection for

pain management in labour (seven studies)

Seven studies randomising 766 women were included in this re-

view (Derry 2012): four studies compared intracutaneous sterile

water injections versus placebo (saline injections) (467 women);

two studies compared subcutaneous sterile water injection ver-

sus placebo (saline injection) (200 women); and one study com-

pared intracutaneous or subcutaneous sterile water injection ver-

sus placebo (saline injection) (99 women).

3.1. Intracutaneous or subcutaneous sterile water injection

versus placebo (blinded controls) for pain management in

labour (six studies, 667 women)

Pain intensity: Although pain intensity was reported in several of

the studies contributing data to this review, the review authors did

not consider that data were presented in a way that was suitable

for inclusion in meta-analysis, or that was clinically meaningful.

Therefore, in this overview we have not set out results for this out-

come. Pain intensity data were, however, reported in an included

non-Cochrane review focusing on sterile water injection described

below.

There was no evidence of a significant difference in assisted vaginal

births (RR 1.31, 95% CI 0.79 to 2.18, six trials, 666 women) or

caesarean section (RR 0.58, 95% CI 0.33 to 1.02, seven trials, 766

women) between the sterile water and placebo groups.


satisfaction with pain relief; sense of control in labour; satisfac-

tion with childbirth experience; effect on mother/baby interac-

tion; breastfeeding; adverse effects for women or infants; admis-

sion to neonatal intensive care unit; Apgar score less than seven

at five minutes; poor infant outcomes at long-term follow-up; or

cost.

3.2. Intracutaneous versus subcutaneous sterile water

injection (one study, 99 women)

Pain intensity: Although pain intensity was reported in the single

study examining this comparison, review authors considered that



data were either unsuitable for inclusion in meta-analysis, or were

not clinically meaningful. Therefore, in this overview we have not

set out results for this outcome.

3.3. Intracutaneous water versus a different intervention

One study compared TENS with sterile water injection and

one examined sterile water versus acupuncture (Dowswell 2009).

These studies have been discussed in the relevant sections below.

See Table 15 for all results relating to sterile water injections.

4. Immersion in water in labour and birth (12 studies)

Twelve studies randomising 3252 women were included in this

review (Cluett 2009). Altogether 11 studies compared immersion

versus no immersion (3052 women); eight compared immersion

versus no immersion in the first stage of labour (2766 women);

one study compared immersion versus no immersion in the sec-

ond stage of labour (120 women) and two studies compared im-

mersion versus no immersion in both the first and second stages

of labour (166 women). One study compared early (< 5 cm di-

lation) versus late (>= 5 cm dilation) immersion during the first

stage of labour (200 women). We have presented results separately

for those studies comparing immersion (early or late) versus no

immersion as opposed to the single study comparing immersion

at different stages during labour.

4.1 Immersion in water during the first or second stage of

labour versus no immersion in water/ standard care (11


Overall, there was little difference between groups for most of the

comparisons including: breastfeeding, assisted vaginal birth, cae-

sarean section, adverse effects for infants, admission to special care

baby unit and Apgar score less than seven at five minutes. The

only differences observed between groups were for pain intensity,

adverse effects for mothers, and satisfaction with childbirth expe-

rience. For all of these outcomes evidence was derived from single

studies.

Pain intensity: In a single trial (120 women) comparing immer-

sion versus no immersion in the first stage of labour significantly

fewer women in the immersion group reported their pain inten-

sity as being moderate to severe at 30 minutes after randomisation

on three different instruments measuring pain intensity (RR 0.75,

95% CI 0.62 to 0.91; RR 0.72, 95% CI 0.58 to 0.90; RR 0.67,

95% CI 0.51 to 0.90). At one hour and two hours after randomi-

sation fewer women in the immersion group reported moderate or

severe pain for two out of the three ordinal scales (one hour - RR

0.76, 95% CI 0.63 to 0.91; RR 0.68, 95% CI 0.53 to 0.86) (two

hours - RR 0.76, 95% CI 0.59 to 0.98; RR 0.72, 95% CI 0.52

to 0.98). There were no significant differences between groups at

three hours after randomisation on any of the three ordinal scales.

Adverse effects for women: In one trial that compared immersion

versus no immersion in the first stage of labour mean systolic,

diastolic and arterial blood pressures were significantly lower in

women in the immersion group, (mean difference (MD) -7.20,

95% CI -13.12 to -1.28; MD -10.20, 95% CI -13.70 to -6.70;

MD -10.50, 95% CI -14.68 to -6.32, 120 women).

Satisfaction with childbirth experience: Of the three trials that

compared water immersion during the second stage with no im-

mersion, one trial (117) showed that significantly fewer women

in the immersion group reported low satisfaction (reported as did

not cope with pushing efforts) with the childbirth experience (RR

0.24, 95% CI 0.07 to 0.80).

None of the following outcomes were analysed in the review: sat-

isfaction with pain relief; sense of control in labour; effect on

mother/baby interaction; poor infant outcomes at long-term fol-

low-up; or cost.

4.2. Immersion in water during early compared with later in

labour (one study 200 women)

Results were reported for two outcomes: adverse effects in infants

and Apgar scores at one minute; there was no significant difference

between groups for either of these outcomes. Results for other

outcomes were not reported.

4.3. Immersion in water versus a different intervention


See Table 16 for all results relating to immersion in water.

5. Aromatherapy for pain management in labour (two

studies)

Two studies randomising 535 women were included in this review

(Smith 2011c): one study compared aromatherapy versus standard

care (513 women); and one study compared aromatherapy using

ginger versus aromatherapy using lemon grass (22 women). None

of the data relating to pain assessment were reported in a way that

allowed the review authors to include them in the analysis. In one

study, data were reported for only one arm of the trial and in the

other median values were presented.

5.1. Aromatherapy versus standard care (one study, 513

women)

There was no evidence of a significant difference between groups

comparing aromatherapy with standard care for assisted vaginal

birth or caesarean section (RR 1.04, 95% CI 0.48 to 2.28, and RR

0.98, 95% CI 0.49 to 1.94 respectively; one trial, 513 women).

There was also no evidence of a significant difference between

groups for admission to neonatal intensive care unit (NICU) (RR

0.08, 95% CI 0.00 to 1.42, one trial, 513 women).



5.2. Aromatherapy (ginger) versus aromatherapy (lemon

grass) (one study, 22 women)

There was no evidence of a significant difference between groups

comparing different types of aromatherapy for assisted vaginal

birth or caesarean section (RR 0.83, 95% CI 0.06 to 11.70, and

RR 2.54, 95% CI 0.11 to 56.25 respectively, one trial, 22 women).

No women in either group had a postpartum haemorrhage and

no babies were admitted to NICU (one trial, 22 women).




tion; breastfeeding; adverse effects for infants; Apgar score less than

seven at five minutes; poor infant outcomes at long-term follow-

up; or cost.

5.3. Aromatherapy versus a different intervention

No studies examined this comparison

See Table 17 for all results on aromatherapy.

6. Relaxation techniques for pain management in labour (11

studies)

6.1. Relaxation techniques versus standard care (11 studies)

Eleven studies involving 1574 women were included in this re-

view (Smith 2011b): six studies compared relaxation in the form

of progressive muscle relaxation, breathing or psycho-prophylaxis

versus standard care (1147 women); two studies compared yoga

versus standard care (270 women); two studies compared music

versus standard care (133 women); and one study compared au-

dio-analgesia versus standard care (24 women). There was consid-

erable variation in these studies in the way pain, pain relief and

satisfaction with the childbirth experience were measured.

Pain intensity: Five of the 11 included trials reported data on

pain intensity as continuous data. A significant difference was

observed between groups in studies comparing relaxation with

standard care in both the latent and active phases of labour (MD

-1.25, 95% CI -1.97 to -0.53, one trial, 40 women; MD -2.48,

95% CI -3.13 to -1.83, two trials, 74 women) and in one study

comparing yoga versus standard care in the latent phase of labour

(MD -6.12, 95% CI -11.77 to -0.47, one trial, 66 women), with a

reduction in pain intensity for the relaxation and yoga groups. No

evidence of a significant difference between groups was observed

for any of the other comparisons (music versus standard care;

audio-analgesia versus standard care). There was no evidence of

significant difference in memory of pain at three-month follow-

up for the one study examining this outcome (relaxation versus

standard care, one trial, 904 women).

Satisfaction with pain relief: Three of the 11 included trials re-

ported data on satisfaction with pain relief. Two trials reported this

as dichotomous data and one trial as continuous data. A signifi-

cant difference was observed between groups comparing relaxation

with standard care (RR 8.00, 95% CI 1.10 to 58.19, one trial, 40

women) and between groups comparing yoga with standard care

(MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women), with

significantly greater satisfaction reported for women in the relax-

ation and yoga groups. No significant difference was observed for

the other comparison (audio-analgesia versus standard care, one

trial, 24 women).

Satisfaction with childbirth experience: Two of the 11 included tri-

als reported data on satisfaction with childbirth experience. A sig-

nificant difference was observed between groups comparing yoga

with standard care (MD 6.34, 95% CI 0.26 to 12.42, one trial,

66 women), with greater satisfaction reported for women in the

yoga group. No evidence of a significant difference was observed

for the other comparison (relaxation versus standard care).

Assisted vaginal birth: Three out of the 11 included trials reported

data on assisted vaginal birth. A significant difference was observed

between groups comparing relaxation with standard care (RR 0.07,

95% CI 0.01 to 0.50, two trials, 86 women), with fewer women in

the relaxation group having assisted vaginal births. No evidence of

a significant difference was observed for a cluster trial comparing

relaxation with standard care (one trial, 904 women).

Caesarean section: Four out of the 11 included trials reported data

on caesarean section. The data could not be combined in a meta-

analysis for one of the comparisons because of significant hetero-

geneity (relaxation versus standard care, three trials [one cluster,

two parallel], 990 women). There was no evidence of a significant

difference for the other comparison (music versus standard care,

one trial, 60 women).

Apgar score less than seven at five minutes: Two out of the 11 in-

cluded trials reported on Apgar scores. There was no evidence of a

significant difference between relaxation versus standard care (one

trial, 34 women). In the yoga versus standard care comparison, no

babies in either group had an Apgar score less than seven at five

minutes.


sense of control; effect on mother/baby interaction; breastfeeding;

adverse effects for women and infants; admission to special care

baby unit/neonatal intensive care unit; poor infant outcomes at

long-term follow-up; or cost.

6.2. Comparisons of different types of relaxation techniques

No studies compared different types of relaxation for pain man-

agement in labour.

6.3. Relaxation versus different interventions

No studies compared relaxation techniques with other types of

interventions to relieve pain in labour.

See Table 18 for all results on relaxation techniques.



7. Acupuncture or acupressure for pain management in

labour (13 studies)

Thirteen studies with data on 1986 women were included in this

review (2391 women in total randomised) (Smith 2011a): eight

studies examined acupuncture and four acupressure; the control

conditions varied, with women in some studies receiving placebo

interventions and in others no intervention. Results for acupunc-

ture and acupressure and for different control conditions were set

out separately in the review. One study compared acupuncture ver-

sus sterile water injection (128 women) (results for this last study

comparing different types of interventions are set out in section

7.3 below).

7.1. Acupuncture or acupressure versus placebo treatments or

standard care (12 studies, 1858 women)

Pain intensity: The tools used to assess pain were not reported in

the review. Seven of the 12 included trials reported data on pain

intensity as continuous data. A significant difference was observed

between groups in a study comparing acupuncture with no treat-

ment (standardised mean difference (SMD) -1.00, 95% CI -1.33

to -0.67, one trial, 163 women) and in studies comparing acu-

pressure with placebo (SMD -0.55, 95% CI -0.92 to -0.19, one

trial, 120 women) and with a combined control (SMD -0.42, 95%

CI -0.65 to -0.18, two trials, 322 women). Women reported less

intense pain in both the acupuncture and acupressure groups for

these comparisons. However, this evidence was generally limited

to single studies. No evidence of a significant difference between

groups was observed for any of the other comparisons (acupunc-

ture versus placebo; acupuncture versus standard care).

Satisfaction with pain relief: The tools used to assess satisfaction

with pain relief were not reported in the review. Two of the 12

included trials reported data on satisfaction with pain relief. A sig-

nificant difference was observed between groups in the study com-

paring acupuncture with placebo; more women were satisfied with

pain relief in the acupuncture group when compared with placebo

(RR 2.38, 95% CI 1.78 to 3.19, one trial, 150 women). No evi-

dence of a significant difference was observed for the acupuncture

versus standard care comparison.

Assisted vaginal birth: Five of the 12 trials reported data on assisted

vaginal birth. A significant difference was observed between groups

in the studies comparing acupuncture with standard care (RR 0.67,

95% CI 0.46 to 0.98, three trials, 704 women), with significantly

fewer women in the acupuncture group having assisted vaginal

births. No evidence of a significant difference between groups was

observed for any of the other comparisons.

Caesarean section: Eight of the 12 trials reported data on caesarean

section. A significant difference was observed between groups in

the study comparing acupressure with placebo (RR 0.24, 95%

CI 0.11 to 0.54, one trial, 120 women), with significantly fewer

women in the acupressure group having caesarean section. There

was no evidence of a significant difference between groups for any

of the other comparisons.

Apgar score less than seven at five minutes: Five of the 12 trials

reported data on Apgar score less than seven at five minutes. There

was no evidence of a significant difference between groups in any

of the trials.

7.2. Comparisons of different types of acupuncture

No studies compared different types of acupuncture.

7.3. Acupuncture versus sterile water injection (one study,

128 women)

A significant difference in satisfaction with pain relief was observed

between groups in a trial comparing acupuncture with sterile water

injections with increased satisfaction reported in the sterile water

group (MD 18.60, 95% CI 11.54 to 25.66, one trial, 128 women).

There was no evidence of significant differences between groups

for assisted vaginal or caesarean birth. Other outcomes were not

reported.


sense of control in labour; satisfaction with childbirth experience;

effect on mother/baby interaction; breastfeeding; adverse effects

for women and infants; admission to special care baby unit/NICU;

poor infant outcomes at long-term follow-up; and cost.

See Table 19 for all results on acupuncture or acupressure

8. Massage, reflexology and other manual methods for pain

management in labour (six studies)

Six trials were included in this review, with data reporting on five

trials and 326 women in the meta-analysis (401 women in total

randomised) (Smith 2012). Only studies examining massage were

identified. Control conditions varied. Four studies examined mas-

sage compared with usual care (225 women). One study exam-

ined massage compared with breathing exercises (28 women) and

one examined massage compared with music. These are reported

separately (101 women).

Overall, there was little difference between groups for most of the

comparisons examining satisfaction with pain relief, sense of con-

trol in labour, assisted vaginal birth, caesarean section or admission

to special care baby unit. The only difference observed between

groups was for pain intensity.

8.1. Massage versus standard care (four studies, 225 women)

In four trials comparing massage with usual care pain intensity

during the first stage of labour was reduced in the massage group

(SMD -0.82, 95% CI -1.17 to -0.47, 225 women). No evidence

of a significant difference between groups for pain intensity was

observed during the second or third stages of labour.



8.2. Comparisons of different manual methods

No studies compared different types of manual methods for pain

management in labour.

8.3. Massage versus a different intervention (relaxation/

music) (two studies 129 women)

In one trial comparing massage with music therapy the number of

women reporting severe pain was significantly lower in the massage

group (RR 0.40, 95% CI 0.18 to 0.89, 101 women). Data were

not in a suitable format for analysis in one trial comparing massage

with relaxation (28 women).


satisfaction with childbirth experience; effect on mother/baby in-

teraction; breastfeeding; adverse effects for women and infants;

Apgar score less than seven at five minutes; poor infant outcomes

at long-term follow-up; or cost.

See Table 20 for all results relating to massage.

9. Transcutaneous electrical nerve stimulation (TENS) for

pain management in labour (17 studies)

Seventeen studies involving 1466 women were included in this

review (Dowswell 2009): thirteen studies examined TENS ap-

plied to the back; two to acupuncture points; and two to the cra-

nium. Fourteen studies compared TENS with placebo or usual

care (1256 women); three studies compared TENS as an adjunct

to epidural analgesia to epidural alone (200 women); and one

study compared TENS versus sterile water injection (23 women).

This study included three arms: TENS, usual care, sterile water.

Results for the TENS versus sterile water comparison are set out

separately.

Overall, there was little difference between groups for most of

the comparisons examining pain intensity, satisfaction with pain

relief or assisted vaginal birth. Any differences observed in these

outcomes were limited to one or two studies, as outlined below.

9.1. TENS (to back, cranium or acupuncture points) versus

placebo / standard care (17 studies, 1455 women)

Pain intensity: In two trials (290 women) comparing TENS to

acupuncture points versus placebo significantly fewer women in

the TENS group reported severe pain during labour compared

with controls (RR 0.41, 95% CI 0.31 to 0.54).

Satisfaction with pain relief: In one trial (90 women) comparing

TENS to acupuncture points versus control (no pain relief ), sig-

nificantly more women in the TENS group were satisfied with

pain relief (RR 4.10, 95% CI 1.81 to 9.29).

Assisted vaginal birth: In one trial (100 women) comparing TENS

to acupuncture points versus placebo, significantly more women

in the TENS group had assisted vaginal births (RR 4.50, 95% CI

1.02 to 19.79).

Other outcomes: There was no evidence of a significant difference

between groups for any of the outcomes relating to caesarean sec-

tion or adverse effects for the infant (fetal distress).

Data were not available in a suitable format for analysis for sense of

control in labour, satisfaction with childbirth experience or Apgar

score (for the last, all data were provided as means).

9.2. Different types of TENS

No studies compared different types of TENS (e.g. TENS to dif-

ferent parts of the body or different intensities).

9.3. TENS versus sterile water injections (one study, 22

women)

Results from a single study comparing TENS with sterile water

injections reported on mean pain scores but results were difficult to

interpret. For other outcomes reported, there were no significant

differences between groups.


effect on mother/baby interaction; breastfeeding; adverse effects

for women; admission to NICU or special care baby unit (SCBU);

poor infant outcomes at long-term follow-up; or cost.

See Table 21 for all results on TENS.

Pharmacological interventions (six reviews)

1. Inhaled analgesia for pain management in labour (26

studies)

Twenty-six studies randomising 2967 women were included in

this review (Klomp 2012). The review presented data for five dif-

ferent comparisons; here we have summarised results under three

headings: inhaled analgesia versus placebo/no treatment; versus

another (different) inhaled analgesia and versus different methods

of pain relief.

1.1. Inhaled analgesia versus placebo (oxygen or compressed

air or no treatment) (nine studies, 1495 women)

In the studies comparing inhaled analgesia with placebo or no

treatment, nitrous oxide was found to offer better pain relief (aver-

age RR 0.06, 95% CI 0.01 to 0.34. two studies, 310 women; MD

-3.50, 95% CI -3.75 to -3.25, one study, 509 women). However,

nitrous oxide was associated with more adverse effects for women

such as nausea, vomiting, dizziness and drowsiness (RR 9.05, 95%

CI 1.18 to 69.32, two studies, 619 women; RR 43.10, 95% CI

2.63 to 706.74, one study, 509 women; RR 113.98, 95% CI 7.09

to 1833.69, one study, 509 women; RR 77.59, 95% CI 4.80 to

1254.96, one study, 509 women) when compared with placebo

or no treatment.



1.2. Inhaled analgesia versus different inhaled analgesia

(different drugs, strength or delivery system)

1.2.1. Inhaled analgesia versus a different type of inhaled

analgesia (nitrous oxide versus flurane derivatives, 14 studies,

752 women)

In the studies comparing different types of inhaled analgesia, mean

pain scores were lower with flurane derivatives and women receiv-

ing flurane derivatives were more likely to have improved pain

relief scores compared with nitrous oxide (average pain score MD

13.87, 95% CI 4.02 to 23.72, three studies, 123 women; pain

relief score MD -16.92, 95% CI -27.64 to -6.20, two studies, 140

women). Substantial heterogeneity was found in the analyses of

pain intensity.

Compared with nitrous oxide, flurane derivatives were associated

with less maternal nausea and vomiting (RR 3.30, 95% CI 1.64 to

6.63, six studies, 378 women; RR 2.66, 95% CI 1.06 to 6.70, four

studies, 261 women), but more drowsiness (MD -12.97, 95% CI

-22.33 to -3.62, two studies, 57 women).

1.2.2 Inhaled analgesia of one strength versus a different

strength (50% nitrous oxide versus 70% nitrous oxide, two

studies, 625 women)

There were no significant differences found for any of the out-

comes in the studies comparing one strength versus a different

strength of inhaled analgesia.

1.2.3. Inhaled analgesia using one type of delivery system

versus a different system (nitrous oxide with or without nasal

supplement, methoxyflurane using Penthrane® analgizer

versus Cyprane® inhaler, two studies, 75 women)


comes in the studies comparing different delivery systems.

1.3. Inhaled analgesia versus different method of pain relief

1.3.1 Inhaled analgesia (nitrous oxide) versus TENS (one

study, 20 women)


comes in the study comparing inhaled analgesia with TENS.


sense of control; satisfaction with childbirth experience; effect on

mother/baby interaction; breastfeeding; admission to special care

baby unit; poor infant outcomes at long-term follow-up; or cost.

See Table 22 for all results relating to inhaled analgesia.

2. Parenteral opioids for maternal pain management in

labour (57 studies)

Fifty-seven studies involving over 7000 women were included in

this large review (Ullman 2010). We have presented results for

three main comparisons: first parenteral opioids versus placebo or

no treatment; second, comparisons between different opioids; and

third, comparisons between parenteral opioids and other meth-

ods of pain management in labour. In view of the complexity of

this review, within each main comparison we have included sub-

sections, and results for intramuscular (IM) and intravenous (IV)

drug administration are set out separately.

Pain intensity was reported in a variety of ways and at different

time points across trials. Twenty-eight of the 57 included trials

reported data on pain intensity. A total of twenty-three compar-

isons included data on pain intensity and significant findings were

observed in five comparisons.

Satisfaction with pain relief was reported in a variety of ways and

at different time points across trials. Only 12 of the 57 included

trials reported data on satisfaction with pain relief. A total of nine

comparisons included data on satisfaction with pain relief and

significant findings were observed in two comparisons.

Satisfaction with childbirth experience was reported in only one

of the 57 included trials.

Breastfeeding was reported in only two of the 57 included trials.

Definitions of breastfeeding were not provided.

2.1. Parenteral opioids versus placebo or no treatment (three

studies, 226 women)

2.1.1. IM opioids versus placebo or not treatment (three

studies, 226 women)

Only two studies comparing an IM opioid (pethidine) with

placebo were included in the review (166 women). In a single study

(50 women) more women in the IM pethidine group had a reduc-

tion in pain score (defined as a reduction in visual analogue scale

score of at least 40 mm) compared with the placebo group (RR

25.00, 95% CI 1.56 to 400.54, one study, 50 women). For other

outcomes (maternal satisfaction with pain relief, assisted vaginal

birth, caesarean section, nausea and vomiting, adverse effects on

the baby, and admission to NICU) there was no clear evidence of

differences between groups. A single study (116 women) reported

that women receiving pethidine were more likely to report sleepi-

ness compared with controls (RR 4.67, 95% CI 2.43 to 8.95).

Other outcomes were not reported in either of these two studies

(satisfaction with childbirth experience, breastfeeding, Apgar score

less than seven at five minutes, sense of control in labour, effect



on mother/baby interaction, poor long-term outcomes in babies

and cost).

One study (60 women) compared IM tramadol versus no treat-

ment. This study reported on only one of the overview’s outcomes:

adverse effects in women (blood loss at delivery). There was no

significant evidence of any difference between groups.

2.1.2. IV opioids versus placebo (no studies)

None of the studies examining IV opioids (including opioids ad-

ministered through PCA systems) were compared with placebo or

no treatment.

2.2. Comparisons of different opioids

2.2.1. IM opioids versus different IM opioids (15 different

comparisons, 36 studies)

A broad range of comparisons was examined, with many com-

parisons confined to evidence from single studies. Studies were

carried out over several decades and in several different countries

and comparisons included IM pethidine versus meptazinol, di-

amorphine, tramadol, dihydrocodeine, pentazocine, nalbuphine

or morphine.

Pain intensity: This outcome was reported for 13 comparisons ex-

amining one type of IM opioid versus another: for 12 comparisons

(predominantly measured in single studies comparing pethidine

with another opioid) there was no significant evidence of differ-

ences between groups. Only one comparison (IM tramadol versus

IM pethidine) examined in four studies (243 women) reported a

statistically significant difference between groups. More women

reported “poor pain relief ” in the IM tramadol group compared

with the IM pethidine groups (RR 1.56, 95% CI 1.10 to 2.21).

See Table 23 for all results relating to pain intensity.

Satisfaction with pain relief: This outcome was reported for three

comparisons.Pooled results for three studies (365 women) exam-

ining IM pentazocine versus IM pethidine found no significant

difference between groups. A single study (10 women) comparing

PCA (IM) meptazinol and PCA (IM) pethidine also reported no

significant difference between groups. In one study fewer women

receiving IM nalbuphine group were dissatisfied with pain relief

compared with those receiving IM pethidine (RR 0.73, 95% CI

0.55 to 0.96, one study, 72 women).

See Table 23 for all results relating to satisfaction with pain relief.

Satisfaction with the childbirth experience: this outcome was not

reported in any of the studies included in this comparison. (Table

23)

Breastfeeding: This outcome was reported for only one study:

there was no evidence of a significant difference between groups

receiving IM meptazinol versus IM pethidine (RR 0.76, 95% CI

0.17 to 3.30, one study, 197 women).

See Table 23 for results relating to breastfeeding.

Assisted vaginal delivery: This outcome was reported for six differ-

ent comparisons (11 studies); there were no significant differences

between groups for any of the comparisons (Table 23).

Caesarean section (CS): The number of women undergoing CS

was reported for five different comparisons (9 studies); there were

no significant differences for any of the comparisons. (Table 23).

Adverse effects: a range of adverse effects was reported, including

nausea, vomiting and sleepiness. Measurement of these outcomes

varied between studies (some studies reported nausea and vomiting

as separate outcomes and some as a combined outcome). The time

at which they were measured also varied considerably, which makes

results difficult to summarise and interpret. Overall, in many of

these trials, women receiving pethidine were more likely to report

adverse effects (including nausea and drowsiness) compared with

women receiving other opioids.

Maternal drowsiness or sleepiness was reported for nine different

comparisons and for eight of these comparisons there were no sig-

nificant differences between women receiving different opioids.

In studies comparing IM tramadol versus pethidine (five studies,

409 women) fewer women in the tramadol group reported sleepi-

ness (RR 0.57, 95% CI 0.33 to 0.97), but there was variation

between the individual studies and substantial heterogeneity was

evident (I2=72%). Results for nausea were reported for six com-

parisons and there were significant differences between groups for

two comparisons: in three studies (391 women) comparing IM

pentazocine with IM pethidine, more women in the pethidine

group reported nausea (RR 0.46, 95% CI 0.24 to 0.90), and in

a single study (301 women) comparing nalbuphine with pethi-

dine, again pethidine was associated with increased rates of nau-

sea (RR 0.62, 95% CI 0.42 to 0.91). Vomiting was recorded for

seven comparisons and for four of these there were differences be-

tween groups; overall women were less likely to experience vom-

iting if they received meptazinol (three studies 1589 women), di-

amorphine (one study, 133 women), nalbuphine (one study, 301

women) and phenazocine (one study 212 women) compared to

groups receiving IM pethidine. In three comparisons, nausea and

vomiting were reported as a single effect: for two comparisons

there was no evidence of significant differences between groups; in

a single study (72 women) comparing nalbuphine and pethidine,

women receiving pethidine were more likely to report nausea and

vomiting. (Table 23)

Adverse effects in infants: a range of adverse effects was reported

including neonatal resuscitation, administration of naloxone, res-

piratory distress and neuro behavioural outcomes. Overall, these

outcomes were reported in single studies and results were mainly

non-significant. Naloxone administration was reported for five dif-

ferent comparisons and there was no significant evidence of dif-

ferences between groups receiving pethidine compared with other

opioids. Numbers requiring neonatal resuscitation were reported

for three comparisons: there was no evidence that infants whose

mothers received pethidine, rather than other opioids, were more



or less likely to need resuscitation. A single study reported mean

scores on a neurological scale at two to four hours post birth (72

babies) and reported lower mean score for babies whose mothers

had received nalbuphine. (Table 23). The number of babies ad-

mitted to special care was reported for four comparisons (mep-

tazinol, tramadol, diamorphine, nalbuphine, four single studies);

in all four cases the control arm received pethidine. There was no

evidence of any significant differences for any of the comparisons.

(Table 23) Similarly, in four comparisons where Apgar scores at

five minutes were examined there was no clear evidence of dif-

ferences between experimental and control groups (all of which

received pethidine). (Table 23)

Sense of control in labour, mother/baby interaction, poor infant

outcomes at long-term follow-up and cost were not reported for

any comparisons. (Table 23)

2.2.2. IV opioids versus different IV opioids (12


Intravenous opioids were compared with other IV opioids in 17

studies although many outcomes were either not reported at all or

were reported in single studies. The types of opioids compared in

studies included: IV pethidine versus IV fentanyl, butorphanol,

pentazocine, remifentanil or nalbuphine, and in some trials opi-

oids other than pethidine were compared with each other: e.g. fen-

tanyl versus alfentanil. In 10 of the studies (seven different com-

parisons) IVs were administered by staff; in

seven studies (five comparisons) IV drugs were administered

through patient-controlled (PCA) systems. In these comparisons,

the regimens (lockout times, size of bolus, rate of background in-

fusion) as well as drugs varied between trials. While we have com-

bined methods of IV administration in our summary (e.g. staff

or patient-controlled), where results suggest differences between

groups we have specified the mode of administration.

Pain intensity: Pain intensity was examined for seven compar-

isons (eight studies). In five comparisons examining different types

of opioid via PCA there was no evidence of differences between

groups. In a single study looking at staff-administered IV opioids,

the mean pain score in the IV fentanyl group was significantly

lower than in the IV pethidine group (MD -0.20, 95% CI -0.34

to -0.06, one study, 105 women). The mean pain relief score (high

score = better pain relief ) was significantly higher in the IV butor-

phanol group compared with the IV pethidine (MD 0.67, 95%

CI 0.25 to 1.09, one study, 80 women) and this finding was sup-

ported by data for mean pain scores one hour after drug admin-

istration which were significantly lower for women in the butor-

phanol group (MD -0.60, 95% CI -1.02 to -0.18, one study, 80

women).

See Table 24 for all results relating to pain intensity.

Satisfaction with pain relief: This outcome was poorly reported;

only four studies, each describing a different IV comparison pro-

vided data on women’s views of their pain relief. Three of the four

studies reported no significant differences between groups; in a

single study, fewer women in the morphine group were satisfied

with their pain relief compared with an IV pethidine group (RR

0.87, 95% CI 0.78 to 0.98, one study, 141 women, staff-admin-

istered).

See Table 24 for all results relating to satisfaction with pain relief.

Satisfaction with childbirth experience was reported in only one

of the 57 included trials. This study found no significant differ-

ence in satisfaction with childbirth experience between the PCA

remifentanil and PCA pethidine groups (RR 1.10, 95% CI 0.40

to 1.74, one study, 68 women). (Table 24)

Breastfeeding: Results for breastfeeding at hospital discharge were

reported in only one study. There was no evidence of a signifi-

cant difference between groups for PCA pentazocine versus PCA

pethidine (RR 1.00, 95% CI 0.85 to 1.17, one study, 23 women).

(Table 24)

Assisted vaginal birth: this outcome was reported for three differ-

ent comparisons. In all three, pethidine was compared with other

opioids, there was no evidence of differences between groups for

any of the comparisons. (Table 24)

Caesarean section: the number of women having CS was reported

in nine studies (eight comparisons, four with staff-administered

IV drug and four PCA). There was no significant evidence of

differences between groups for any of the comparisons. (Table 24)

Adverse effects for women including nausea and vomiting (re-

ported either separately or together) and sleepiness were recorded

for several comparisons: for most of these there were no clear dif-

ferences between women receiving different types of IV opioids.

Sleepiness was reported for three comparisons; there a difference

between groups for only one comparison. In one study with 105

participants, women receiving IV fentanyl were reported to be less

sedated than those receiving IV pethidine (RR 0.05, 95% CI 0.00

to 0.82). Nausea and vomiting were reported for five comparisons

and again most (4/5) did not find significant differences between

groups; in a single study (200 women) fewer women in the IV bu-

torphanol group experienced nausea and/or vomiting compared

with those in pethidine group (RR 0.04. 95% CI 0.00 to 0.67).

(Table 24)

Adverse effects for infants: The number of babies requiring nalox-

one or resuscitation was reported for four and two comparisons re-

spectively, and neuro-behavioural scores (at different time points)

were reported for four comparisons. None of these comparisons

showed significant differences between groups. (Table 24)

The number of babies admitted to special care was only reported

in one study (17 women) and there was no evidence of differences

between groups. While babies with Apgar scores less than seven at

five minutes was reported for five comparisons (six studies) again,

none showed statistically significant differences for babies whose

mothers had received different opioids.

None of the studies examining IV comparisons reported results

for mothers’ sense of control in labour, effect on mother-baby

interaction, poor infant outcomes at long-term follow-up or cost.



2.3. Parenteral opioids versus different interventions

2.3.1. Parenteral opioids versus a different method of pain

management (TENS) (three comparisons, three studies, 305

women)

Three studies compared parenteral opioids with TENS; each ex-

amined a different comparison (IV pethidine, IM pethidine and

IM tramadol). For most outcomes there was very little evidence

available (data from none or only one of the studies) and there

were few statistically significant differences between trial arms.

Pain intensity was reported for two studies (290 women); there

was no clear evidence of any difference between groups receiving

TENS compared with opioids. Two studies (104 women) reported

satisfaction with pain relief and again there was no significant

difference between women in the TENS and opioid groups. There

was no evidence of differences between groups for assisted vaginal

birth or caesarean section (one study, 200 women).

Adverse effects were reported for two studies (290 women); women

in the opioid groups were more likely to report drowsiness or

nausea and vomiting compared with those in the TENS group,

although the 95% CIs were very broad for both outcomes (RR

8.96, 95% CI 1.13 to 71.07; RR 14.06, 95% CI 1.96 to 100.61

respectively). Fetal distress was reported in one study (200 women)

and there was no evidence of differences between groups. (Table

24)

Satisfaction with the childbirth experience, breastfeeding, admis-

sion to special care, Apgar score less than seven, sense of control

in labour, mother-baby interaction, poor infant outcomes at long-

term follow-up and cost were not reported in any of the three

studies.

2.3.2. Parenteral opioids versus a different method of pain

management (epidural)

Thirty-three studies compared epidural analgesia with IM or IV

opioids; findings from these comparisons are discussed below in the

section on epidural versus non-epidural or no analgesia in labour.

3. Non-opioid drugs for pain management in labour (18

studies)

Eighteen studies randomising 2733 women were included in this

review (Othman 2012). The non-opioid drugs included paraceta-

mol, the non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. as-

pirin, ibuprofen), sedatives (e.g. barbiturates, phenothiazine, and

benzodiazepines), anti-spasmodics (e.g. hyoscine), and anti-his-

tamines (e.g. promethazine, hydroxyzine). There were three main

comparison groups: 14 studies compared non-opioid drugs with

placebo or no treatment (2003 women); three studies compared

one type of non-opioid drug with a different non-opioid drug or

different doses of the same drug (590 women); and three studies

compared non-opioid drugs with opioids (563 women). Three

studies had more than two study arms and so data from different

arms have been included in more than one comparison group.

Most outcomes were not reported for most of the comparisons.

Where outcomes were reported, there was little evidence of any

difference for most comparisons. Any differences observed were

mainly limited to one or two studies, as outlined below.

3.1. Non-opioid drugs versus placebo (14 studies, 2003

women)

Sedatives were found to offer better pain relief (MD -22.00, 95%

CI -35.86 to -8.14, one trial, 50 women), better satisfaction with

pain relief (RR 1.59, 95% CI 1.15 to 2.21, two trials, 204 women)

and better satisfaction with childbirth experience (RR 2.16, 95%

CI 1.34 to 3.47, one trial, 40 women) when compared with

placebo or no treatment. Anti-histamines were also found to offer

better satisfaction with pain relief (RR 1.80, 95% CI 1.16 to 2.79,

1 trial 223 women) when compared with placebo or no treatment.

There was no evidence of a significant difference for any of the

other comparisons.

3.2. Non-opioid drug versus a different type or dose of a non-

opioid drug (three studies 590 women)

Women receiving the anti-histamine hydroxyzine were more likely

to express satisfaction with pain relief than those receiving the anti-

histamine promethazine (RR 1.21, 95% CI 1.02 to 1.43, one trial,

289 women).There was no evidence of a significant difference for

any of the other comparisons reported.

3.3. Non-opioid drug versus a different type of intervention

(opioid) (three studies, 563 women)

Women receiving non-opioid drugs (NSAIDs or anti-histamines)

were less likely to be satisfied with pain relief when compared to

women having opioids (RR 0.50, 95% CI 0.27 to 0.94, one trial,

76 women; RR 0.73, 95% CI 0.54 to 0.98, one trial, 223 women).


sense of control in labour; effect on mother/baby interaction; ad-

mission to special care baby unit/neonatal intensive care unit; poor


See Table 25 for all results relating to non-opioid drugs.

4. Local anaesthetic nerve block for pain management in

labour (12 studies)

Twelve studies randomising 1549 women were included in this

review (Novikova 2012). The review presented data for the fol-

lowing comparisons: local anaesthetic nerve block versus placebo

(one study, 200 women); local anaesthetic nerve block versus a dif-

ferent local anaesthetic agent for nerve block (eight studies, 1120

women); local anaesthetic nerve block versus a different interven-

tion (local anaesthetic nerve block versus opioids (two studies,

129 women); and local anaesthetic nerve block versus non-opioids

(one study, 100 women)).

For all comparisons results were either not reported or there were



no significant differences between groups except for the following

results derived from single studies:

4.1. Local anaesthetic nerve block versus placebo (one study,

200 women)

Women who received local anaesthetic nerve block were more

likely to be satisfied with pain relief compared with women who re-

ceived placebo (RR 32.31, 95% CI 10.60 to 98.54, one study, 198

women). However, mothers and infants of mothers who received

local anaesthetic nerve block were more likely to experience ad-

verse effects (mother - giddiness, sweating, tingling of lower limbs;

infant - bradycardia) compared with women who received placebo

(RR 29.00, 95% CI 1.75 to 479.61, one study, 200 women).

4.2. Local anaesthetic nerve block versus a different type of

local anaesthetic nerve block (eight studies, 1120 women)

In studies comparing one type of local anaesthetic nerve block

with a different type of local anaesthetic nerve block, there was

no evidence of a significant difference between groups for any

outcomes analysed (satisfaction with pain relief; assisted vaginal

birth; caesarean section; adverse effects for mother; Apgar score

less than seven at five minutes).

4.3. Local anaesthetic nerve block versus a different interven-

tion (opoid or non-opioid drugs) (three studies, 229 women)

Women who received local anaesthetic nerve block were more

likely to be satisfied with pain relief compared with women who

received intramuscular pethidine (RR 2.52, 95% CI 1.65 to 3.83,

one study, 109 women). There were no significant differences be-

tween local anaesthetic nerve blocks and opioids for assisted vagi-

nal birth or caesarean section (two studies, 129 women) or be-

tween local anaesthetic nerve blocks and non-opioids for satisfac-

tion with pain relief or caesarean section (one study, 100 women).


pain intensity; sense of control; satisfaction with childbirth expe-

rience; effect on mother/baby interaction; breastfeeding; admis-

sion to special care baby unit; poor infant outcomes at long-term

follow-up; or cost.

See Table 26 for all results relating to local anaesthetic nerve block.

5. Epidural versus non-epidural or no analgesia in labour (38

studies)

Thirty-eight studies randomising 9658 women were included in

this review (Anim-Somuah 2011). The majority of studies, (33

studies), compared epidural analgesia with IM or IV opioids. In

five of the included studies epidural was compared to no analgesia

during labour.

In this section of the overview we were not able to present separate

results for epidural versus no intervention/placebo and epidural

versus an alternative method of pain management. This is because,

in the original review there was no separate analysis for these dif-

ferent comparisons. Similarly, while most of the women in control

groups received IM or IV opioid drugs, there was considerable

variation in the agents, doses and modes of administration. How-

ever, in the original review results for these different comparisons

were analysed together, therefore we have not specified control

conditions in the results described below.

Results relating to comparisons between different types of epidu-

ral (combined spinal-epidural versus epidural analgesia) were the

subject of a different review, and are described in a separate section

below.

5.1. Epidural versus non-epidural or no analgesia in labour

(38 studies)

Epidural was found to offer better pain relief (MD -3.36, 95%

CI -5.41 to -1.31, three trials, 1166 women), a reduced risk of

acidosis in the newborn (RR 0.80, 95% CI 0.68 to 0.94, seven tri-

als, 3643 women) and a reduced risk of naloxone administration

in the newborn (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645

women) compared with controls. However, epidural analgesia was

associated with an increased risk of assisted vaginal birth (RR 1.42,

95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypoten-

sion (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women),

motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials,

322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six

trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82

to 60.39, three trials, 283 women). There was an increased risk of

caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97,

11 trials, 4816 women). There was no evidence of a significant

difference in the risk of caesarean section overall (RR 1.10, 95%

CI 0.97 to 1.25, 27 trials, 8417 women), long-term back ache

(RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar

score less than seven at five minutes (RR 0.80, 95% CI 0.54 to

1.20, 18 trials, 6898 women) and maternal satisfaction with pain

relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women).

Substantial heterogeneity was found in the analyses of pain in-

tensity and maternal satisfaction. This could not be explained by

subgroup or sensitivity analyses.


effect on mother/baby interaction; breastfeeding; poor infant out-

comes at long-term follow-up; or cost.

See Table 27 for all results on epidural.

6. Combined spinal-epidural versus epidural analgesia in

labour (27 studies)

Twenty-seven studies involving 3303 women were included in this

review (Simmons 2012). There was considerable heterogeneity be-

tween trials with respect to the drug combinations administered,

both intrathecally and epidurally, the timing of subsequent dosing

after initial analgesia and the method of epidural drug delivery. In

the context of categorising the epidural drug dose/concentration

used, the term traditional was used for trials where the epidural

local anaesthetic (LA) concentration was the equivalent of bupiva-

caine 0.25% or more; lower concentrations were defined as low-



dose. In the CSE groups, there were three types of interventions;

LA plus opioid, opioid alone, or null CSE where there was a dural

puncture with no intrathecal injection of drugs. Using these defi-

nitions the comparisons fell into six categories as detailed below:

1. LA plus opioid CSE versus traditional epidural;

2. LA plus opioid CSE versus low-dose epidural;

3. opioid only CSE versus traditional epidural;

4. opioid only CSE versus low-dose epidural;

5. opioid only CSE versus test LA/opioid epidural;

6. null CSE versus traditional epidural.

Analyses were performed on two separate sets of comparisons.

The first set involved all combined spinal-epidural (CSE) variants

versus traditional epidurals and the second set was all CSE forms

versus low-dose epidurals and variants.

In comparison with traditional epidurals, the mean time of on-

set of effective analgesia was slightly shorter for CSE by approx-

imately three minutes (MD -2.87, 95% CI -5.07 to -0.67, two

studies, 129 women) and there were fewer assisted vaginal births

(RR 0.80, 95% CI 0.67 to 0.97, six studies, 1015 women) and

less urinary retention (RR 0.86, 95% CI 0.79 to 0.95, one study,

704 women) in women in the CSE group. In comparison with

low-dose epidural, again the mean time of onset of effective anal-

gesia was shorter for the CSE group by approximately five min-

utes (average MD -5.42, 95% CI -7.26 to -3.59, five studies, 461

women) and more women in the CSE group reported effective

pain relief at 10 minutes after the first injection (RR 1.94, 95%

CI 1.49 to 2.54, one study, 101 women). However, more women

in the CSE group reported pruritus compared with the low-dose

epidural group (average RR 1.80, 95% CI 1.22 to 2.65, 11 stud-

ies, 959 women). Time to onset of effective analgesia and pruri-

tus showed substantial heterogeneity. There was no evidence of a

significant difference between comparison groups for any of the

other outcomes analysed.




tion; breastfeeding; poor infant outcomes at long-term follow-up;

or cost.

See Table 28 for all results relating to combined spinal-epidural.

Non-Cochrane Systematic reviews

Non-pharmacological interventions (one review)

Sterile water injection, (eight studies)

Eight studies randomising 783 women were included in this re-

view (Hutton 2009). The review included randomised controlled

trials comparing intracutaneous or subcutaneous injections of ster-

ile water with a placebo (saline water) or with other non-pharma-

cological methods of pain relief such as TENS or acupuncture.

Five studies used intracutaneous sterile water injections and three

used subcutaneous sterile water injections. The control groups

consisted of: acupuncture (one study); TENS and usual care (one

study); and isotonic saline injections (six studies). There was over-

lap in terms of the studies included in this review and the Cochrane

reviews on intracutaneous sterile water injection, acupuncture and

TENS. However, this non-Cochrane review included additional

data on pain intensity and caesarean section, not analysed in the

sterile water Cochrane review, and has been included for this rea-

son.

In comparison with placebo or other intervention groups, there

was a significant reduction in VAS pain score in the sterile water

group at three different time-points: 10 to 30 minutes following

administration of the intervention (WMD -26.04 mm, 95% CI

-34.14 to -17.94, four studies, 289 women); at 45 to 60 minutes

(WMD -36.27 mm, 95% CI -50.80 to -21.74, five studies, 542

women); and at 90 to 120 minutes following administration of

the intervention (WMD -27.74 mm, 95% CI -39.03 to -16.45,

five studies, 488 women). However, substantial heterogeneity was

evident within each of these analyses of pain scores. All analyses of

pain score used random-effects. A significant reduction was also

observed in caesarean sections in a meta-analysis of all eight studies

comparing any sterile water injection with placebo (normal saline

injection) or with other non-pharmacological interventions such

as TENS or acupuncture (RR 0.51, 95% CI 0.30 to 0.87, I2=

0%).



tion with childbirth experience; effect on mother/baby interaction;

breastfeeding; assisted vaginal birth; adverse effects for mother and

baby; admission to special care baby unit; Apgar score less than

seven at five minutes; poor infant outcomes at long-term follow-

up; and cost.

See Table 29 for all results relating to sterile water injection.

Pharmacological interventions (two reviews)

Epidural ropivacaine versus bupivacaine, (23 studies)

Seven studies randomising 2074 women were included in this

review (Halpern 2003a). The review included randomised con-

trolled trials comparing epidural ropivacaine with epidural bupi-

vacaine. There was no evidence of any statistically significant dif-

ference between drugs in the incidence of any obstetric or neona-

tal outcomes assessed (pain intensity; satisfaction with pain relief;

assisted vaginal birth; caesarean section; hypotension; nausea or

vomiting; Apgar score less than seven at five minutes).

None of the following outcomes were reported within the review:

sense of control in labour; satisfaction with childbirth experience;

effect on mother/baby interaction; breastfeeding; admission to

special care baby unit; poor infant outcomes at long-term follow-

up; and cost.

See Table 30 for all results relating to ropivacaine versus bupiva-

caine.



Intrathecal opioids, (24 studies)

Twenty-four studies randomising 3513 women were included in

this review (Mardirosoff 2002). The review included randomised

controlled trials comparing any analgesia using intrathecal opi-

oid with any non-intrathecal regimen. Three intrathecal opioids

were included (sufentanil, fentanyl, morphine), with or without

various doses of intrathecal or epidural bupivacaine. The controls

consisted of different doses of epidural or intrathecal bupivacaine,

epidural lidocaine, combinations of epidural bupivacaine and dif-

ferent doses of epidural sufentanil or fentanyl and intravenous

sufentanil.

A significant increase in the risk of fetal bradycardia was observed

for women in the intrathecal opioid group compared to the con-

trol group (RR 29.6, 95% 13.6 to 64.6, 11 studies, 855 women)

and for maternal pruritus in the intrathecal groups compared with

controls who had not received opioids (RR 29.6, 95% CI 13.6 to

64.6, 11 studies, 855 women). There was no evidence of a sig-

nificant difference for maternal pruritus when intrathecal opioids

were compared with IV or IM opioid controls (average RR 1.71,

95% CI 0.97 to 3.02). There was no evidence of any significant

differences between groups for any other outcomes examined (as-

sisted vaginal birth; caesarean section; fetal heart rate abnormali-

ties; Apgar score less than seven at five minutes).


pain intensity; satisfaction with pain relief; sense of control in

labour; satisfaction with childbirth experience; effect on mother/

baby interaction; breastfeeding; poor infant outcomes at long-term

follow-up; and cost.

See Table 31 for all results relating to intrathecal opioids.

D I S C U S S I O N

Summary of main results

The 15 Cochrane systematic reviews included a total of 257 trials.

The non-Cochrane systematic reviews included a total of 55 tri-

als. Most of the comparisons within each individual review were

within treatment comparisons e.g. one type of inhaled analgesia

compared to a different type of inhaled analgesia. There was a

paucity of placebo controlled trials with less than half, 41% (105),

of all included studies comparing the intervention with placebo

or no treatment. Similarly, only 18% (47) of all included studies

compared an intervention with a different type of intervention

according to the hierarchy of interventions. Most of these studies

comparing one form of intervention with another were confined

to one review and examined epidural versus parenteral opioids. In

other reviews, head-to-head comparisons between different types

of interventions were rare, and results were largely derived from

a small number of studies (e.g. TENS versus sterile water, one

study; inhaled analgesia versus TENS, one study; opioids versus

TENS, three studies; non-opioids versus opioids, three studies; lo-

cal anaesthetic nerve blocks versus opioids, two studies; and local

anaesthetic nerve blocks versus non-opioids, one study) (Figure

2).

Based on the following comparisons:

1. intervention versus placebo or standard care;

2. different forms of the same intervention (e.g. one opioid

versus another opioid);

3. one type of intervention versus a different type of

intervention (e.g. TENS versus opioid).

We have categorised interventions into “ What works,” “What

may work”, and “Insufficient evidence to make a judgement”, as

outlined.

WHAT WORKS

There is considerable evidence to suggest that epidurals (including

combined spinal epidurals (CSE)), and more limited evidence to

suggest that inhaled analgesia are effective for managing pain in

labour, but these interventions are not without adverse effects.

Epidural

There was a reduction in mean pain scores for women in the epidu-

ral group when measured during the whole of labour (three studies,

1166 women) and during the first (four trials, 589 women) and

second stages of labour (three trials, 559 women) in comparison

with non-epidural (parenteral opioids) or no analgesia. However,

considerable heterogeneity was observed for these analyses. There

was no significant difference observed for any of the other effec-

tiveness outcomes examined (patient satisfaction with pain relief;

sense of control in labour; satisfaction with childbirth experience).

More women in the epidural group had assisted vaginal births (23

trials, 7935 women) and experienced adverse effects such as hy-

potension (eight trials, 2789 women), motor blockade (three tri-

als, 322 women), fever (six trials, 2741 women) or urinary reten-

tion (three trials, 283 women) in comparison with non-epidural

(parenteral opioids) or no analgesia. More women in the epidu-

ral group had caesarean sections for fetal distress (11 trials, 4816

women) in comparison with non-epidural (parenteral opioids) or

no analgesia, although there was no evidence of a significant dif-

ference between groups in the overall caesarean section rate (seven

trials, 8417 women). The risk of acidosis and the requirement for

naloxone was lower in infants in the epidural group compared

with the non-epidural group (seven trials, 3643 women; one trial,

2645 women). There was no evidence of a significant difference

between groups in admissions to special care baby unit (seven tri-

als, 3125 women) or Apgar scores (18 trials, 6898 women).

Combined spinal epidural (CSE)

In comparison to traditional epidural, the mean time of onset of

effective analgesia was slightly shorter for CSE by approximately

three minutes (two trials,129 women). In comparison to low-dose

epidural, again the mean time of onset of effective analgesia was

shorter for the CSE group by approximately five minutes (five

trials, 461 women). However, considerable heterogeneity was ob-

served for the CSE versus low dose comparison. More women in



the CSE group reported effective pain relief at 10 minutes after the

first injection in comparison with the low dose epidural (one trial,

101 women), but there was no significant difference observed be-

tween CSE and low dose epidural for satisfaction with pain relief

(seven trials, 520 women). Other effectiveness outcomes (sense of

control; satisfaction with childbirth experience) were not reported.

CSE was associated with fewer assisted vaginal births in compari-

son to traditional epidural (six trials, 1015 women), but there was

no evidence of a significant difference in assisted vaginal birth be-

tween CSE and low dose epidural (11 trials, 1612 women). There

was no evidence of a significant difference in Caesarean section

for any of the comparisons: CSE versus traditional epidural (six

trials, 1015 women); or CSE versus low dose epidural (15 tri-

als, 1960 women). No differences in adverse effects for women

were observed for the following comparisons: post dural puncture;

known dural tap; blood patch; nausea and vomiting; hypoten-

sion; headache; and sedation. In contrast, fewer women in the

CSE group experienced urinary retention compared with tradi-

tional epidural (one trial, 704 women), but more women in the

CSE group experienced pruritus in comparison with the low dose

epidural group (11 trials, 959 women). There was no evidence of

a significant difference in admissions to special care baby unit or

Apgar scores for any of the comparisons: CSE versus traditional

epidural; CSE versus low dose epidural .

Inhaled analgesia

In comparison with placebo, fewer women in the inhaled analgesia

group experienced severe or extreme pain during the first stage of

labour (two trials, 310 women) and the mean pain score in one

large study (one trial, 509 women) was lower. There was insuffi-

cient evidence on efficacy in the comparison of inhaled analgesia

with TENS, with non-significant findings for pain intensity (one

trial, 19 women). More women experienced vomiting (two stud-

ies, 619 women), nausea (one study, 509 women), dizziness (one

study, 509 women) and drowsiness (one study, 509 women) with

inhaled analgesia when compared to placebo. There were no data

on safety outcomes for the comparison of inhaled analgesia with

TENS.

WHAT MAY WORK

There is some evidence to suggest that immersion in water, relax-

ation, acupuncture, massage, local anaesthetic nerve blocks and

non-opioid drugs may assist in managing pain in labour. Few ad-

verse effects are reported. Evidence was mainly limited to individ-

ual trials.

Immersion

Individual trials comparing immersion in water during the first

stage of labour with no immersion or standard care suggested

a reduction in pain (one trial, 120 women) and an increase in

satisfaction with childbirth experience for those in the immersion

group during the second stage of labour (one trial, 117 women).

However, in other studies using different pain intensity measures

or measurement at different time-points, there was no evidence

of a significant difference between groups for pain intensity (one

trials, 141 women) and satisfaction with the childbirth experience

(one trial, 60 women). Mean blood pressure was lower during the

first stage of labour in women in the immersion group in one trial

(120 women), but there was no evidence of a significant difference

between groups for any other of the safety outcomes.

Relaxation

A reduction in pain (two trials, 74 women; one trial 66 women),

greater satisfaction with pain relief (one trial, 40 women; one trial

66 women) and childbirth (one trial, 66 women) were observed in

individual trials of relaxation methods (breathing, yoga) in com-

parison with standard care. However, for other comparisons of re-

laxation methods (music; audio-analgesia), there was no evidence

of a significant difference for these same outcomes. Fewer assisted

vaginal births were observed in two trials comparing relaxation

with standard care (two trials, 86 women), but no evidence of a

significant difference was observed in one cluster trial of the same

comparison (one trial, 904 women).

Acupuncture

A reduction in pain (one trial, 120 women) and greater satisfaction

with pain relief (one trial, 150 women) was observed in individual

trials of acupuncture or acupressure in comparison with no treat-

ment or placebo. In one trial comparing acupuncture with sterile

water injection, more women in the sterile water group were satis-

fied with their pain relief (one trial, 128 women). There was no ev-

idence of a significant difference for pain and satisfaction with pain

relief for other comparisons of acupuncture with placebo or stan-

dard care. Fewer assisted vaginal births (three trials, 704 women)

and caesarean sections (one trial, 120 women) were observed in

comparisons of acupuncture and acupressure with standard care

or placebo. In other comparisons of acupuncture or acupressure,

there was no evidence of a significant difference in assisted vaginal

births (one trial, 208 women; one trial 163 women; one trial, 222

women) or caesarean sections (three trials, 448 women; two trials,

506 women).

Massage

In four trials comparing massage with standard care, pain inten-

sity during the first stage of labour was reduced in the massage

group during the first stage of labour (four trials, 225 women).

No evidence of a significant difference between groups for pain

intensity was observed during the second (two trials, 124 women)

or third stages of labour (two trials, 122 women). In one trial

comparing massage with music therapy, the number of women

reporting severe pain was lower in the massage group (one trial,

101 women). There was no evidence of a significant difference in

assisted vaginal births (two trials, 105 women), caesarean sections

(two trials, 105 women) or admission to special care baby unit

(one trial, 44 women) in trials comparing massage with standard

care. There were no data on safety outcomes in trials comparing

massage with relaxation or music therapy.

Local anaesthetic nerve blocks

More women in the local anaesthetic nerve block group (PCB

1% lidocaine) were satisfied with pain relief (degree of pain relief



rated as excellent/complete) compared with the placebo group,

(one trial, 198 women). There were no data on pain intensity,

sense of control and satisfaction with the childbirth experience

for this comparison. Women who received local anaesthetic nerve

blocks were more likely to be satisfied with pain relief compared

with women who received intramuscular pethidine (one trial, 109

women), but there was no evidence of a significant difference be-

tween local anaesthetic nerve blocks and (IM promethazine) for

satisfaction with pain relief (one trial, 20 women). Local anaes-

thetic nerve blocks (using lidocaine) were associated with more

adverse effects for women and infants (women - sweating, giddi-

ness, tingling of lower limbs; infants - bradycardia; one trial, 200

women) in comparison with placebo. There was no evidence of

a significant difference in assisted vaginal births (two trials, 129

women) or caesarean sections (two trials, 129 women) between

local anaesthetic nerve blocks and opioids (IM pethidine or PCA

fentanyl).

Non-opioid drugs

There was insufficient evidence on the effectiveness and safety of

most non-opioid drugs. However, evidence from single trials sug-

gests that some drugs may work. Non-opioid drugs (sedatives)

were found to offer better pain relief (one trial, 50 women), better

satisfaction with pain relief (sedatives and anti-histamines: two tri-

als, 204 women; one trial, 223 women) and better satisfaction with

the childbirth experience (one trial, 40 women) when compared

with placebo. There was no evidence of a significant difference

for any of the other comparisons of non-opioids (anti-histamines)

for pain intensity and satisfaction with pain relief. Women having

non-opioid drugs (NSAIDs or anti-histamines) were less likely to

be satisfied with pain relief when compared with women having

opioids (one trial, 76 women).There was little data and no evi-

dence of a significant difference for any of the comparisons of non-

opioids for safety outcomes.

INSUFFICIENT EVIDENCE TO MAKE A JUDGEMENT

There is insufficient evidence to make a judgement on whether or

not hypnosis, biofeedback, sterile water injection, aromatherapy,

TENS, and parenteral opioids, are more effective than placebo or

other interventions for pain management in labour.

Hypnosis

There was no evidence of a significant difference between hypnosis

and either no hypnosis/standard care or a different type of hypnosis

for all effectiveness outcomes analysed (satisfaction with pain relief;

satisfaction with childbirth experience). There was no evidence of

a significant difference in: breastfeeding (one trial, 266 women);

assisted vaginal births (three trials, 414 women); caesarean sections

(three trials, 867 women); adverse effects for women and infants

(one trial, 305 women); admissions to the neonatal intensive care

unit (two trials, 345 women); or Apgar score less than seven at five

minutes (one trial, 305 women).

Biofeedback

There was no evidence of a significant difference between biofeed-

back and standard care for assisted vaginal birth (two trials, 103

women) or caesarean section (two trials, 103 women). No other

data on effectiveness or safety outcomes were reported.

Sterile water injection

In the sterile water versus placebo comparison, data were either

not in a suitable format for analysis (pain intensity) or were not

reported (satisfaction with pain relief; sense of control in labour;

satisfaction with childbirth experience). In the non-Cochrane re-

view, in comparison with placebo or other intervention groups,

there was a significant reduction in VAS pain score in the sterile

water group at three different time-points. However, substantial

heterogeneity was evident within each of these analyses of pain

score.

There was no evidence of a significant difference in assisted vaginal

births (six trials, 666 women) or caesarean section (seven trials,

766 women) between the sterile water and placebo groups. In

the non-Cochrane review, a significant reduction was observed in

Caesarean sections in the sterile water group. However, this review

included sterile water injection versus any comparison (placebo,

TENS, acupuncture) (eight trials, 828 women).

Aromatherapy

There were no data on any effectiveness outcomes. There was no

evidence of a significant difference between groups (aromatherapy

versus standard care) in assisted vaginal births, caesarean sections

or admission to special care baby unit (one trial, 513 women).

TENS

In two trials comparing TENS to acupuncture points with

placebo, fewer women in the TENS group reported severe pain

during labour (two trials, 290 women). No significant differences

were observed for pain in two other trials comparing TENS to the

back with placebo or usual care (two trials, 299 women). In one

trial comparing TENS to acupuncture points with standard care,

more women in the TENS group were satisfied with their pain

relief (one trial, 90 women) but in five trials comparing TENS to

the back with placebo or standard care, there was no difference

between groups for satisfaction with pain relief (five trials, 452

women). There were no significant differences observed between

groups for assisted vaginal births, caesarean sections or adverse ef-

fects for infants.

Parenteral opioids

More women in the IM pethidine group had a reduction in pain

score compared with the placebo group (one trial, 50 women).

In studies comparing parenteral opioids with a different inter-

vention, TENS, pain intensity was reported for two studies (290

women); there was no clear evidence of any difference between

groups receiving TENS compared with opioids. Two studies (104

women) reported satisfaction with pain relief, and again there was

no significant difference between women in the TENS and opioid

groups.

There was no clear evidence of differences between groups (par-

enteral opioids versus placebo) for other outcomes (assisted vaginal

birth, caesarean section, nausea and vomiting, adverse effects on

the baby, and admission to NICU). A single study (116 women)



reported that women receiving pethidine were more likely to re-

port sleepiness compared with controls. Other safety outcomes

were not reported.

In studies comparing parenteral opioids with TENS, there was no

evidence of differences between groups for assisted vaginal birth

or caesarean section (one trial, 200 women). Adverse effects were

reported for two studies (290 women); women in the opioid group

were more likely to report drowsiness or nausea and vomiting com-

pared with those in the TENS group although 95% CIs were very

broad for both outcomes. Fetal distress was reported in one study

(200 women) and there was no evidence of differences between

groups. Other safety outcomes were not reported.

Overall completeness and applicability ofevidence

The overview has included 18 reviews focusing on 15 different

methods of pain relief in labour and most reviews considered sev-

eral different comparisons. The overview has focused on methods

of pain management that are explicitly intended to relieve pain

and has not included more broadly based interventions.

There remain gaps in the research evidence and some of the evi-

dence presented in this overview has serious limitations. Most out-

come data included in meta-analyses is drawn from only one or

two trials within each of the reviews. There are exceptions to this,

for example in the epidural and combined spinal epidural reviews

a larger number of trials contribute data, but even within these

reviews the variability in the results in individual trials (and the

high heterogeneity) means that results may still be difficult to in-

terpret. Therefore, it may be difficult, under these circumstances,

to generalise findings to other settings.

Most reviews included comparisons with placebo or between dif-

ferent types of the same intervention. However, at the outset we

had hoped that we would be able to compare directly different

methods of pain relief in terms of efficacy and safety; this proved

problematic. Very few of the reviews included any direct compar-

isons with other interventions (Figure 2). Where different meth-

ods were compared (e.g. inhaled analgesia versus TENS), results

for particular outcomes were mainly confined to evidence from

single studies. Thus, with the exception of the comparisons be-

tween epidural versus parenteral opioids, we were not able to draw

any conclusions from direct comparisons regarding the relative ef-

fectiveness and drawbacks of different ways of managing pain in

labour.

We considered making indirect comparisons in order to address

questions concerning the relative performance of different meth-

ods of pain relief. This would have involved using statistical meth-

ods to examine different interventions, each compared with the

same comparator (e.g. placebo), but which had not been directly

compared with each other. However, such methods can only be

used meaningfully if the populations recruited to the trials, and

the way outcomes are measured, are broadly similar. Therefore, we

decided that indirect comparisons would not be appropriate, due

to differences between reviews in terms of contextual and other

factors. For example, women in trials of IM opiates were recruited

over a long period (some trials dating back to the 1930s) while

other methods of pain management have only been introduced

into obstetric and midwifery practice (and been studied in trials)

in the last twenty years. Improved hospital facilities, changes in

custom and practice (for example where women give birth and

whether or not they have support from partners or family) and

the options for pain relief available to women are likely to have

changed women’s expectations about pain relief and their expe-

rience of childbirth. The way pain has been measured has also

altered considerably. Few early trials used VASs or validated pain

scales, and in some older studies, women were not asked to rate

their pain at all. Comparing like with like in terms of populations

and outcomes did not seem possible. This meant that we were

not able to provide a simple answer to the question about which

methods are most effective, safe and acceptable to women.

Many of our prespecified outcomes were not reported in the con-

tributing studies/review. In Table 32 and Table 33 we have pro-

vided a summary of outcomes reported within each of the re-

views. Sense of control in labour and breastfeeding were very rarely

reported within included trials in individual reviews. Effect on

mother/baby interaction, poor infant outcomes at long-term fol-

low-up and cost were never reported. As these are all important

outcomes to women or to providers of healthcare services, it is

surprising that they do not receive more research attention.

The very many ways outcomes were defined and measured in trials

led to problems in interpreting findings. It was not always clear

which tool was used to measure pain or which component of the

McGill pain questionnaire (three components - visual analogue

scale, verbal response scale, present pain intensity scale). Some

trials just reported “pain scores” and presented data as mean scores.

The majority of studies used visual analogue scales, but it was

not always clear how the extremes of the scales were marked and

whether the line was subdivided in any way. Many trials only

presented results graphically or presented median and interquartile

range. Some studies measured pain and pain relief as dichotomous

outcomes; but again there was no consistency in the meaning of

the outcome: a score could mean no pain (or complete relief )

or manageable pain (some relief ). There was similar variation for

satisfaction with pain relief. Many trials also reported mean or

median values for Apgar score. Accordingly, a lot of data could not

be analysed according to our criteria.

It was sometimes difficult to interpret the outcome data within

reviews, as some reviews used different terminology to that spec-

ified within the generic protocol. This was probably due to the

variation of reporting of outcomes in the individual trials. For ex-

ample, in some trials, pain was reported as “memory of pain” ,

“degree of pain relief ”, “perception of pain relief ” and experience

of childbirth as “difficulty of labour.” This made it difficult to map

outcome data to outcomes from the core list.



Interpreting findings from individual reviews and summarising

findings within this overview were complicated by the variation in

both the experimental and control conditions examined within re-

views. In this overview, interventions in individual studies have not

been described in detail; settings, exact content and the intensity

or dose of interventions may have varied; some interventions may

have required specialised staff (e.g. acupuncture) and the training

and skills of operators are likely to have varied over time and loca-

tions. Control conditions are frequently not described at all in tri-

als; understanding what the terms “routine care”, “standard care”

or “no intervention” mean in studies carried out over a period of

more than fifty years in countries across the globe is particularly

difficult. Within this overview we have not been able to provide

details of participants, interventions (and control conditions) in

individual trials and we have given only limited information about

the way outcomes were measured in studies and reviews; we would

therefore encourage readers to consult the individual reviews to

obtain more information on these important factors.

A further difficulty in interpreting evidence and applying findings

from the overview to clinical situations relates to gaps in the evi-

dence concerning co-interventions and to the general lack of con-

sistency and clear information about when in labour interventions

were implemented and outcomes measured. In practice, women

in labour may opt for more than one method of pain relief and

may use different interventions simultaneously (e.g. inhaled anal-

gesia and parenteral opioids) or consecutively (e.g. TENS and then

epidural). Single interventions may be only partially effective and

methods that may provide adequate relief during the early stages

of labour may not do so as labour progresses. Without evidence

about pain relief at different stages in labour it remains difficult to

make recommendations to women when pain intensity is likely to

vary considerably as labour progresses.

No subgroup analyses were conducted on the pre-specified sub-

groups (spontaneous labour versus induced labour; primiparous

versus multiparous; term versus preterm birth; continuous sup-

port in labour versus no continuous support). This was due to the

low number of studies contributing data within the meta-analyses

and also due to a lack of clear subgroup data provided within the

reviews e.g. no data on continuous support in labour was reported

upon within the reviews.

Quality of the evidence

All fifteen of the Cochrane systematic reviews used the domain-

based evaluation for assessments of risk of bias as outlined in Chap-

ter 8 of the Cochrane Handbook for Systematic Reviews of Inter-ventions (Higgins 2011). None of the included systematic reviews

used the GRADE approach to assess the quality of evidence across

studies for each important outcome. We have therefore based our

assessments of the quality on the assessments reported in the ’Risk

of bias’ tables in the included systematic reviews. The risk of bias

of included trials within the Cochrane reviews was variable, but

generally considered to be high.

The proportion of studies assessed as being at low risk of bias in

the non-pharmacological and pharmacological reviews are sum-

marised in Table 6, Table 7. A higher proportion of studies in the

non-pharmacological reviews were considered to be at low risk of

bias for the domains of sequence generation (54% versus 31%)

and allocation concealment (40% versus 27%). A higher propor-

tion of studies in the pharmacological reviews were considered to

be at low risk of bias for blinding of participants, personnel and

outcome assessors (38%, 38%, 25% versus 20%, 18%, 31%). As-

sessment of blinding was not always conducted for all three groups

e.g. some reviews just assessed blinding as a single entity e.g. aro-

matherapy review, combined spinal epidural review. A higher pro-

portion of studies in the pharmacological reviews were considered

to be at low risk of bias for selective outcome reporting and other

potential threats to validity (49%, 41% versus 26%, 39%). An

equivalent number of studies were assessed as low risk of bias for

the domain of incomplete outcome assessment.

All three non-Cochrane systematic reviews used the Jadad scale

(Jadad 1996) or a modified version to assess the methodological

quality of included studies. The Cochrane Collaboration advises

against the use of such scales: these are thought to be a poor way

of assessing risk of bias, as they omit important considerations

and are largely concerned with reporting rather than conduct. The

Jadad scale is based on assessment of three items: method of ran-

domisation; blinding; and withdrawals and dropouts. This scale

has a maximum of five points, with a score of five indicating the

best possible score. In the epidural ropivacaine versus bupivacaine

review (Halpern 2003a), 17 out of 23 studies (74%) were assessed

as being high quality (with a score of three or more). In the in-

trathecal opioids review (Mardirosoff 2002), the median quality

score of the 24 included studies was reported to be 3.5 (range 1 to

5). The sterile water injection review used an initial version of the

Jadad scale (Jadad 1996), which was based on eleven items. The

maximum possible score for this initial instrument is 13 points.

In the sterile water injection review (Hutton 2009), seven out of

eight studies (88%) were assessed as being high quality (with a

score of 10 or more).

The methods used in Cochrane reviews were assessed using the

AMSTAR rating scale described above. As all Cochrane reviews

followed a generic protocol specifying methods, scores were high

for all reviews. For the non-Cochrane reviews scores were less high;

this was generally because some aspects of the review process may

not have been explicit in the published reviews. Findings regarding

the quality of contributing reviews are set out in Table 10, Table

11, Table 12.

Potential biases in the overview process

We are aware that there was a risk of introducing bias at all stages

in the overview process. We took a number of steps to try to re-



duce this. For non-Cochrane reviews, evidence of using systematic

methods was part of our criteria for selecting reviews for inclu-

sion. For Cochrane reviews, all reviews used a protocol that aimed

to minimise bias. For the overview, two review authors indepen-

dently assessed eligibility for inclusion of reviews, and carried out

data extraction. Data checks were carried out by a third author.

One potential source of bias relates to us, being the authors of some

of the included Cochrane reviews. One advantage of this is that

we are well informed of the weaknesses and strengths on which

these reviews build. No ’Summary findings’ tables were produced

within individual reviews, which limits our ability to assess overall

quality of the evidence against each of our core outcomes.

There is also a risk of bias arising from the fact that not all of the

contributing reviews had been completed at the time of prepar-

ing the overview. Four of the 15 included Cochrane reviews were

in draft form; while all had been submitted for publication in

The Cochrane Library, they had not been revised after peer review,

or approved for publication. Therefore, the findings we have re-

ported in this overview for these four reviews (examining hypno-

sis (Madden 2012), inhaled analgesia (Klomp 2012), non-opioid

drugs (Othman 2012) and combined spinal epidural (Simmons

2012)) are based on the draft reviews submitted by the authors for

editorial consideration. We plan to check all results and make any

necessary corrections in the first update of the overview.

However, it is not possible to eliminate all risk of bias; evidence

synthesis is not an exact science and involves judgement. We would

encourage readers to consider all of the additional tables to assist

them in interpreting results.

Agreements and disagreements with otherstudies or reviews

Many of the non-Cochrane reviews that we excluded from this

overview focused on the same methods of pain management as

the included Cochrane reviews. For the reviews that included ran-

domised controlled trials, there was considerable overlap in the

studies contributing evidence, despite some differences in search

strategies and selection criteria. In view of this overlap, for our

primary outcomes, it is therefore not surprising that the overall

findings of included and excluded reviews were generally in agree-

ment.

Findings for hypnosis from the Cochrane review were inconclu-

sive. This is in line with an earlier review of non-pharmacolog-

ical interventions for pain relief in labour, Simkin 2004a, that

concluded, at that time, there was insufficient evidence to draw

conclusions about the effectiveness of hypnosis and findings. The

included Cochrane review focusing on sterile water injection sug-

gested that there was some limited evidence that this method of-

fers some relief from pain. A review by Fogarty 2008 concluded

that sterile water injection had a beneficial effect on pain and the

included non-Cochrane review Hutton 2009 concurs with this.

Immersion in water was the subject of several excluded reviews

(Benfield 2002; Huntley 2004; Simkin 2002; Simkin 2004a).

While Simkin 2002 suggests that immersion in water reduces

labour pain, the evidence was drawn from non-randomised stud-

ies. The overall conclusion of this and the other reviews was

that there were few differences between intervention and control

groups for most outcomes and for many outcomes there was in-

sufficient evidence from trials to draw any firm conclusions.

For relaxation techniques, massage and reflexology, again other

reviews agree that more evidence is needed (Huntley 2004; Simkin

2002; Simkin 2004a).

The value of acupuncture for pain relief in labour was examined

by Cho 2010, Lee 2004 and Smith 2009. The results of these

reviews are consistent with the findings in the included Cochrane

review; while evidence from single studies suggests that acupunc-

ture reduces pain scores and results in increased satisfaction with

pain relief compared with controls, overall the evidence is mixed,

and for many outcomes there is insufficient evidence to draw firm

conclusions. Cho 2010 also points to the mixed methodological

quality of trials examining this intervention and concludes that the

current evidence from trials does not support the use of acupunc-

ture in labour.

An early review carried out by Carroll 1997 concluded that the

evidence on TENS was weak. While the amount of evidence on

TENS has increased, the evidence remains inconclusive. Although

many women seem to like TENS, it is not clear whether it is an

effective means of relieving pain in labour.

The conclusion of the included Cochrane review on inhaled anal-

gesia is reflected in the findings of another review. Rosen 2002a

suggests that inhaled analgesia offers safe, reasonably effective pain

relief for many women. The review by Klomp 2012, included in

this overview, however, highlights some of the adverse effects (such

as nausea and drowsiness) associated with some types of inhaled

analgesia.

Drawing conclusions regarding the effectiveness and safety of par-

enteral opioids has been hampered by the large number of studies

examining different types, doses and methods of administration

of opioids. Despite the large number of studies focusing on this

widely used form of pain relief, very few studies compare the effects

and adverse effects of different drugs. A decade ago Bricker 2002

indicated the paucity of evidence regarding the relative effects and

the adverse effects of different opioids and called for more research

directly comparing the most frequently used drugs. Many of the

questions raised by that review remain unanswered.

A relatively large number of excluded reviews focused on the use

of epidurals. Again findings are broadly similar to those in this

overview. In earlier studies there was some concern that epidurals

increased the risk of interventions in labour; in particular there was

a suggestion that rates of CS were higher in women who received

epidurals. However, in some reviews at least part of the evidence on

labour interventions was drawn from observational studies rather

than trials (Lieberman 2002; Morton 1994; Thorp 1996; Zhang

1999). In the current overview, while there was no strong evidence



that, compared with controls, women receiving epidural analgesia

were at increased risk of CS overall, the rate of CS for fetal distress

was greater, as was assisted vaginal birth. While there is now good

evidence that epidural offers good pain relief, there is also evidence

that some women experience adverse effects, in addition to any

risks associated with instrumental birth. Other non-Cochrane re-

views shed more evidence on different types of epidural and dif-

ferent drug regimens (including PCEA) (e.g. Halpern 2009).

An outcome which was considered in very few trials or in included

reviews, was the cost of interventions to healthcare providers, in-

cluding both the direct costs of interventions and the costs of

treating adverse effects and complications in women associated

with different types of labour analgesia. Huang 2002 examined

the costs associated with epidural analgesia; overall however, we

found little evidence on this important process outcome.

A gap in the evidence in this overview relates to broader interven-

tions that may increase women’s comfort and sense of control in

labour, which in turn may increase women’s sense of well being,

their ability to maintain control, and which may mitigate the ex-

perience of pain. Hodnett 2002, in a review of factors which affect

women’s experience of giving birth and their satisfaction with their

labour and birth, pointed to several factors which are important to

women. These include the amount of support from caregivers, the

quality of women’s relationships with caregivers and their sense of

involvement in decision-making. Designing interventions which

operationalise these factors in clinical trials is challenging, but evi-

dence from surveys and qualitative research has demonstrated their

importance to women, and underlines the need for high qual-

ity obstetric and midwifery care, where women are consulted and

their views are respected.

Within the scope of this overview, we have been unable to eval-

uate the impact on pain in labour of broadly based interventions

such as continuity of caregiver, the value of childbirth prepara-

tion classes, mobility in labour and the impact of different types

of physical environment for the birth (including home birth) on

pain in labour. Other Cochrane reviews focus on these important

topics, (Hatem 2008; Hodnett 2007).

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Most methods of non-pharmacological pain management are non-

invasive and appear to be safe for the mother and baby, however

their effectiveness is unclear due to limited high quality evidence.

There is more evidence to support the efficacy of pharmacological

methods but these also have more known adverse effects. Thus,

epidural analgesia provides effective pain relief but at the cost of

increased medical intervention including increased incidence of

instrumental vaginal birth.

It remains important to tailor methods used to an individual

woman’s wishes, needs and individual circumstances (this may in-

clude judgements about anticipated duration of labour, condition

of the infant, or whether the labour is augmented).

Implications for research

A major challenge in compiling this overview, and the individual

systematic reviews on which it is based, has been the variation in

use of different outcome measures in different trials, particularly in

assessment of pain and in its relief. This has made it difficult to pool

results from otherwise similar studies, and to derive conclusions

from the totality of evidence.

Other important outcomes have simply not been assessed in tri-

als; thus, despite concerns for 30 years or more about the effects

of maternal opiate administration during labour on subsequent

neonatal behaviour and its influence on breastfeeding, only two

out of 57 trials of opiates reported breastfeeding as an outcome.

We therefore strongly recommend that the outcome measures,

agreed through wide consultation for this project, are used in future

trials of methods of pain management. Future trialists may, of

course, wish to supplement these core outcome measures with

additional topic-specific or trial-specific outcomes.

Further trials are needed particularly for non-pharmacological

methods of pain management. There were very few data for hyp-

nosis, biofeedback, sterile water injection, aromatherapy and mas-

sage with much < 1000 women recruited in total to all trials of

each method. For TENS, there were more trials and more women

recruited, but also uncertainty about its value. In the UK at least,

TENS is popular with women, very widely recommended by

midwives, but unsupported by the national guideline developer,

NICE. This discordance between the views of women, clinicians

and guidelines reflects the poor evidence base and the uncertainty

should be resolved by a definitive trial.

Pain management in labour is a very high priority for consumer

groups. Health funding agencies need to consider if their priorities

match with those of consumer groups.

A C K N O W L E D G E M E N T S

David Tovey for his contributions to the development of the

overview.

We thank the Editorial Staff of the Cochrane Pregnancy and Child-

birth group for their help in preparing the overview.

We thank Gill Gyte, PCG Consumer Group Co-ordinator, for her

help in writing the plain language summary for the overview.

NISCHR Cymru Children and Young People’s Research Network

supported Sue Jordan’s travel to attend a meeting of the authors



and members of the Cochrane Pregnancy and Childbirth Group

in Liverpool in 2010.

As part of the pre-publication editorial process, this overview has

been commented on by five peers (an editor and four referees who

are external to the editorial team), five members of the Pregnancy

and Childbirth Group’s international panel of consumers and a

statistical adviser.

The National Institute for Health Research (NIHR) is the largest

single funder of the Cochrane Pregnancy and Childbirth Group.

The views and opinions expressed therein are those of the authors

and do not necessarily reflect those of the NIHR, NHS or the

Department of Health.

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A D D I T I O N A L T A B L E S

Table 1. Non-Cochrane reviews: characteristics of excluded reviews

Name of Review Description of review Reason for exclusion

Arnal 2009 This paper examined IV remifentanil for

pain relief in labour. (The paper is in Span-

ish and eligibility assessment was carried

out using the abstract only)

This review examines IV remifentanil and

this topic is covered in a recently updated

Cochrane review

Aveline 2001 This review examined epidural and com-

bined spinal epidural. The main focus of

the review is on the duration of labour and

the mode of delivery. It appeared that only

five studies were included, although others

were discussed in the text. There did not

appear to have been any systematic assess-

ment of bias. (This paper was published in

French, so this assessment mainly relied on

details in the abstract)

The topic of this review is covered in a re-

cently updated Cochrane review

Benfield 2002 This review focused on hydrotherapy for

pain relief in labour.There was no descrip-

tion of the methods used to carry out

this review. There was no systematic search

strategy or method of data extraction, no

clear inclusion and exclusion criteria. There

was no systematic assessment of risk of bias.

All types of studies were included. There

was no meta analysis, rather a narrative de-

scription of findings

This was not a systematic review.

Bricker 2002 This systematic review examined parenteral

opioids. Cochrane methods were used and

This systematic review of parenteral opi-

oids, has been superseded by a recently up-



Table 1. Non-Cochrane reviews: characteristics of excluded reviews (Continued)

analysis was carried out using Review Man-

ager software

dated Cochrane systematic review

Bucklin 2002 The review appeared to have been carried

out in a systematic manner. The search cri-

teria, comparisons, inclusion and exclusion

criteria were stated along with outcomes.

It was not clear that there was a system-

atic quality assessment of studies. One mea-

sure of quality was stated to be publica-

tion in a peer reviewed journal. There was

no mention of domain based quality assess-

ment but in the tables in the review there

were notes re study design that included

risk of bias e.g.. It was stated if the study was

blinded and whether staff collecting out-

come data were blinded

The topic of this review is covered in an

included systematic review

Capogna 2004 This review was a mainly narrative sum-

mary of findings from RCTs and other re-

views (with meta-analysis) focusing on var-

ious types of epidural and CSE. It examined

different doses and types of drugs and com-

parisons. The main focus was on neonatal

outcome. The methods of the review were

not described. There was no search strat-

egy specified, no clear inclusion and exclu-

sion criteria, and no systematic assessment

of quality

Not a systematic review.

Carroll 1997 This review examines TENS in labour. The

review methods were described. The search

strategy and inclusion and exclusion crite-

ria were specified. Outcomes included anal-

gesic effect and adverse effects. There was

systematic assessment of study quality in-

cluding blinding and attrition. The review

included 8 RCTs. The review was carried

published in 1997 and the more recent

Cochrane TENS review examined all of the

eight included trials along with other more

recent RCTs

A more recent Cochrane review examines

TENS for pain relief in labour

Carroll 1997a This is an update of Carroll 1997 and in-

cludes 10 RCTs.

A more recent Cochrane review examines

TENS for pain relief in labour

Cho 2010 This review focusing on acupuncture for

pain relief in labour uses Cochrane meth-

ods and Review Manager software was used

This review covers the same topic as a

Cochrane review.




to carry out meta-analysis

Choi 2003 This review was not examining pain man-

agement in labour, rather it focused on the

incidence of headache following epidural



Cyna 2004a There has been a more recent Cochrane re-

view on the same subject by the same au-

thor



Fogarty 2008 This review on intradermal sterile water

injections for the relief of low back pain

in labour provides a narrative summary of

findings from reviews. There is no meta-

analysis and there has been a more recent

Cochrane review on the same topic



Habib 2006 This review mainly focused on patients un-

dergoing surgery rather than women in

labour

The primary focus of this review was not

on women in labour.

Hager 1999 This is a critique of an earlier review. This is not a systematic review.

Halpern 1998 This is a systematic review of the effects

of epidural versus parenteral opioid anal-

gesia on the progress of labour. There has

been a more recent Cochrane review on the

same subject, epidural versus non-epidural,

which includes opioids as the non-epidural

arm



Halpern 2005a This is a well conducted review which up-

dates earlier publications by same author



Halpern 2003b This is not a systematic review. This is not a systematic review.

Halpern 2005b This is a narrative review considering find-

ings from other systematic reviews and in-

dividual RCTS. It was not clear that there

was a systematic search or assessment of in-

dividual study quality. The review focuses

on PCEA vs a continuous infusion. The

review also discusses studies where PCEA

plus a continuous background infusion are

compared with PCEA alone; and examines

different types of PCEA drugs

This is not a systematic review.




Halpern 2009 This review used systematic methods to as-

sess different types of patient controlled

epidural analgesia. The search methods

were described (search 1998 to 2008). The

review examined a range of different com-

parisons:

1. PCEA with background infusion vs no

background infusion

2. PCEA ropivacaine vs PCEA bupivacaine

3. High vs low PCEA background doses/

lockout times and bolus doses, and differ-

ent methods of administering drugs

There was no meta- analysis. Main findings

for each study are set out in tables and sum-

marised in the text

No data available from meta-analyses.

Hodnett 2002 This review focuses on all of the primary

outcomes of the overview but examines

broader questions and draws on descriptive

studies. It provides a very useful summary

of literature on satisfaction with pain relief

Not a systematic review including only

RCTs.

Huang 2002 This review examines economic issues re-

lating to pain relief in labour a topic which

is rarely addressed in trials

This is not an effectiveness review.

Huntley 2004 This is a review focusing on a range of com-

plementary and alternative techniques for

pain relief in labour (acupuncture, hypno-

sis, biofeedback, sterile water injection and

massage along with “respiratory autogenic

training”)

The review included clear inclusion, exclu-

sion criteria, a search strategy and inde-

pendent data extraction. There was an as-

sessment of methodological quality (Jadad

score). The review included RCTs and

quasi RCTs. There was no meta-analysis

due to “statistical heterogeneity amongst

the included studies. Results are set out in

tabular and narrative form

This review covers areas already covered in

included Cochrane reviews

Koehn 2002 This is a review looking at studies ex-

amining childbirth education/ antenatal

classes. The reviewer used a systematic

search mechanism although it was not clear

how studies were selected for inclusion.

The review included both qualitative and

quantitative studies but 11/12 studies were

This is not a systematic effectiveness re-

view. Narrative summary of findings from

mainly descriptive studies




descriptive and there was one before and

after study. No RCTs were included. There

was no systematic evaluation of risk of bias.

Some of the included studies included out-

comes relating to pain perception and satis-

faction with the childbirth experience, but

this was not the main focus of the review.

There was no meta analysis or quantitative

summary of findings. Results were reported

in narrative form and in descriptive tables

Kotaska 2006 This review examines epidural versus par-

enteral opiates. The review included a

search of MEDLINE and the The CochraneLibrary. There was no systematic assess-

ment of risk of bias. Results were reported

in tables and in the text. A recently updated

Cochrane review covers the same topic

A recently updated Cochrane review covers

the same topic.

Kuczkowski 2004 This is not a systematic review, it is a gen-

eral summary of the literature on regional

analgesia


Lally 2008 This review used systematic methods but it

is not an effectiveness review and included

both qualitative and quantitative studies

describing women’s perceptions of pain re-

lief during childbirth. Results were sum-

marised in tables and the text

This review included non-randomised

studies.

Larkin 2009 This is not a systematic review but a quali-

tative analysis of papers reporting women’s

experiences of childbirth


Lee 2004 Systematic review examining acupuncture

for pain relief in labour. There was a com-

prehensive search of 7 databases; assessed

methodological quality. All included stud-

ies are in more recent Cochrane systematic

review

A recently updated Cochrane review covers

the same topic.

Lee 2011 This is not a systematic review but a letter

relating to Cho 2010.


Leeman 2003a This paper focused on non-pharmacologi-

cal methods; It was not clear that this was

a systematic review, there was no descrip-

tion of review methods. It was not clear

This is not a systematic review, rather a nar-

rative summary of findings from reviews

and trials




if there was a search strategy. There was

some description of the quality of the in-

cluded studies but this was not systematic.

There was no meta-analysis. Findings were

set out in tables and text. The review in-

cluded Cochrane and other systematic re-

views along with other RCTs. It focused on

support in labour, sterile water injection,

massage, baths and warm water. This re-

view has been superceded by more recent

Cochrane reviews

Leeman 2003b This is a broad overview of reviews and

RCT evidence.


Leighton 2002 This is an update of a well-conducted sys-

tematic review (Halpern 1998) . The re-

view focuses on epidural vs parenteral opi-

oids in labour in relation to progress in

labour and rate of caesarean section. A sys-

tematic search was carried out (1980-2001)

and details of the search strategy and results

of the search are provided. There was in-

dependent data extraction by two review-

ers and a systematic assessment of quality

(Jadad score). The review includes meta-

analysis. This review is now out of date

and has been superseded by a more recent

Cochrane review

Superseded by more recent Cochrane re-

view.

Leighton 2003 This is not a report of a systematic review.

This paper discussed a range of study de-

signs and considered the evidence relating

to labour outcomes

Not a systematic review but draws on find-

ings of earlier systematic review by same

author

Lieberman 2002 This review included a search strategy and

systematic methods for extracting data.

There was no systematic assessment of

study quality using a domain-based risk of

bias assessment tool, rather the strengths

and weaknesses of study designs and anal-

yses were considered. The review looked at

both RCTs and observational studies com-

paring epidural vs opioids and epidural vs

no epidural. Outcomes included rates of

CS, assisted delivery, duration of labour

and adverse neonatal outcomes. More re-

cent Cochrane reviews have examined these

More recent Cochrane reviews examine the

same comparisons in RCTs




comparisons

Littleford 2004 This is a thorough review of a range of

methods for pain relief in labour. The main

focus of the review is on adverse effects of

analgesia on the fetus and newborn. Al-

though there was a systematic literature

search there was no systematic assessment

of risk of bias. The review cited other

reviews and included discussion of both

randomised and non-randomised studies.

There was no meta-analysis and results are

presented in narrative form

Not a systematic review.

Liu 2004 This systematic review examined low-dose

epidural compared with opioids in nulli-

parous women. Outcomes included rates

of CS, assisted delivery, duration of labour.

Systematic methods; search strategy de-

scribed, included RCTs only, systematic as-

sessment of study quality using Scottish

intercollegiate guideline network checklist

(which includes the same broad areas of risk

of bias as the Cochrane risk of bias tool);

systematic methods for data extraction and

meta-analysis. The focus is on nulliparous

women only and the comparison has been

examined in a more recent Cochrane re-

view

More recent Cochrane review available.

Lopard 2006 This is not a systematic review. It was not

clear that there was a systematic search

strategy or clear inclusion and exclusion cri-

teria. There was no systematic assessment

of risk of bias. The results are reported as a

narrative summary


Marucci 2007 This review looks at epidural and combined

spinal epidural in nulliparous women. The

main outcomes are CS, assisted delivery

and neonatal and newborn outcomes. In-

cluded both RCTs and cohort studies.

The review used systematic methods; the

search strategy was described (1990-2006)

. The studies were assessed for quality us-

ing standard measures (Jahad score for tri-

als). There were standard methods used for

data collection and meta-analysis was per-

formed

Recently up-dated Cochrane reviews covers

the same area.




Mayberry 2002 This review looks at adverse effects of

epidural. Included RCTs. The review used

systematic methods; the search strategy

was described (1990-2000). The studies

were assessed for quality. Standard meth-

ods were used for data collection. Meta-

analysis was not performed rather the re-

sults are described narratively. Recently up-

dated Cochrane reviews cover the same area

Topic covered in recently updated

Cochrane reviews.

Minty 2007 This review focuses on intrathecal analge-

sia as an alternative to epidural. There was

a systematic search and the strategy is de-

scribed. The review includes all study types

(reviews, RCTs and observational stud-

ies) and there was no clear systematic as-

sessment of the quality of the evidence.

The review covers a topic not covered by

Cochrane reviews but without a clear as-

sessment of risk of bias results are difficult

to interpret

The review includes a range of study de-

signs.

Morton 1994 This review looks at epidural in nulliparous

women. The main outcomes are CS, as-

sisted delivery and neonatal and newborn

outcomes. Included both RCTs and other

types of studies. The review used some sys-

tematic methods; the search strategy was

described There were standard methods

used for data collection and meta-analysis

was performed. There was no systematic as-

sessment of study quality and risk of bias.

Recently up-dated Cochrane reviews cover

the same area

Review includes non-randomised studies,

no systematic assessment of study quality.

Topic covered in more up to date Cochrane

reviews

Nystedt 2004 This review looks at the use of epidural.

. Included both RCTs and other types of

studies. The review used some systematic

methods; the search strategy was described.

The studies were assessed for quality based

on study design (high, moderate or low

scientific quality) but there was no system-

atic assessment of risk of bias. Recently up-

dated Cochrane reviews cover the same area

Recently up-dated Cochrane reviews cover

the same area.

Reynolds 2002 This review examines epidural vs par-

enteral opioids; the primary focus is on

studies reporting fetal acid-base as an






outcome. The review includes both ran-

domised trials and non-randomised stud-

ies. A search strategy is described but there

did not appear to be any systematic as-

sessment of study quality. The topic of

this review is covered in a recently updated

Cochrane review

Reynolds 2010 This is not a systematic review but is a gen-

eral narrative summary of methods of pain

relief in labour and their effects on the baby


Rosen 2002a This review looks at paracervical block. A

search strategy was described but the au-

thor describes the review as non-exhaus-

tive. The search included MEDLINE and

the Cochrane library. The studies included

RCTs to examine the effects of analgesia

on fetal bradycardia but other studies were

included to describe adverse effects. There

was no systematic assessment of study qual-

ity. The topic of this review has been cov-

ered in a recently updated Cochrane review

The topic of this review has been covered

in a recently updated Cochrane review

Rosen 2002b This review looks inhaled analgesia. A

search strategy was described. The search

included MEDLINE and The Cochrane Li-brary. The studies included RCTs but other

studies were included to describe adverse

effects. It was not clear that there was a

systematic assessment of study quality but

included studies were described as “low to

moderate risk of bias”. The topic of this re-

view has been covered in a recently updated

Cochrane review

The topic of this review has been covered

in a recently updated Cochrane review

Sharma 2003 This review examines epidural analgesia

drawing on evidence from randomised tri-

als and non-randomised studies. It is not a

systematic review and it was not clear that

there was a search strategy or a systematic

assessment of study quality

This not a systematic review. Regional

analgesia is covered in recently updated

Cochrane Reviews

Sharma 2004 This is not a systematic review. This paper

reports findings of a retrospective analysis

of individual patient data collected in a se-

ries of trials over a 7 year period in the same

hospital; a subset of nulliparous women are

included in the sample in this meta-analy-





sis. There was no search and no systematic

assessment of risk of bias

Shiflett 2011 This is not a review. It is a letter comment-

ing on the findings of another review. Cho

- acupuncture review

This is not a review.

Simkin 2002 This review focuses on five methods to re-

lieve pain in labour including broad based

interventions such as continuous support

in labour, warm baths, maternal positions

and mobility in labour and massage and

intradermal water. It included RCTs and

non-randomised studies including before

and after studies. There was a search strat-

egy but there was no clear assessment of risk

of bias. There was no meta-analysis. Re-

sults were presented in narrative form and

in tables. The review includes broad base

interventions which we have not included

as methods of pain relief in labour; massage

and water injections are covered in recently

updated Cochrane reviews

Includes non randomised studies and fo-

cuses on broad based interventions

Simkin 2004a This overview focuses on 13 non-pharma-

cological methods to relieve pain in labour

including broad based interventions such

as continuous support in labour, warm

baths, maternal positions and mobility in

labour and massage and intradermal water.

It draws on findings from a series of system-

atic reviews (including Cochrane reviews)

. There was a search strategy but there was

no clear assessment of risk of bias in the re-

views included. There was no meta-analy-

sis. Results were presented in narrative form

and in tables. The review includes broad

base interventions which we have not in-

cluded as methods of pain relief in labour;

massage and water injections and relaxation

methods are covered in recently updated

Cochrane reviews

This is not a systematic review. It is a nar-

rative review.

Sleth 2006 This is not a systematic review. There was

a search strategy but the more recent data

was selected to underpin this discussion of

paracervical block. The topic is covered in a

recently updated Cochrane review. (Assess-

ment from English abstract; original full ar-

Not a systematic review. Cochrane review

covers the same topic




ticle published in French)

Smith 2009 This review looks at acupuncture during

pregnancy and childbirth. It was carried

out by the author of a recently updated

Cochrane review on acupuncture in labour

included in this overview

Topic covered in recently updated

Cochrane review.

Thavaneswaran 2006 This systematic review looks at the safety

and efficacy of thoracic and lumbar par-

avertebral block in surgical patients. The

review does not examine pain relief during

labour

This review examines pain relief for surgery

(not during childbirth)

Thorp 1996 This review included evidence from both

RCTs and non-randomised studies. There

was a search strategy but no systematic as-

sessment of risk of bias or study quality. The

review focuses on epidural analgesia which

is covered in recently updated Cochrane re-

views

The review focuses on epidural analge-

sia which is covered in recently updated

Cochrane reviews

Van De Velde 2005 This is not a systematic review. It is a nar-

rative review of various types of neuraxial

analgesia and focuses specifically on brady-

cardia


Van de Velde 2009 This is not a systematic review but a gen-

eral narrative summary and discussion of

methods of neuraxial analgesia in labour


Van der Vyver 2002 This is a systematic review of RCTs com-

paring PCEA versus Continuous Infusion

for labour.

This topic is covered by more recent reviews

on epidural.

Writer 1998 This is not a systematic review - a report

of 6 RCTs which were conducted and then

the results pooled in a meta-analysis.


Wunsch 2003 This literature review includes animal and

medical studies, case reports, not RCTs.

Review of pain in pregnancy, not labour

and addiction medicine


Zhang 1999 This review included both RCTs and ob-

servational studies. Search date up to 1997.

This topic is covered by more recent

Cochrane reviews on epidural

Zhou 2008 This review includes RCTs comparing local

versus systemic application of opioids for

labour analgesia.

This topic is covered by a more recent

Cochrane review.



CS: Caeserean section; PCEA: Patient Controlled Epidural Analgesia; RCT: randomised controlled trial

Table 2. Characteristics of included Cochrane systematic reviews - non-pharmacological interventions

Review title Date of search No. Studies in-

cluded

(No. Patients in

included stud-

ies)

Inclusion crite-

ria for “Types of

participants”

Comparison in-

terventions (no.

studies)

Outcomes for

which data were

reported

that could be

included in an

analysis

Summary

of quality of evi-

dence in reviews

(risk of bias)

Hypno-

sis for pain man-

agement during

labour and child-

birth (Madden

2012)

7 September

2011

7 studies in 3

countries (Aus-

tralia, USA, UK)

between 1986

and 2010

(1213 women)

Pregnant women

including

women in high

risk groups e.g.

preterm

labour or follow-

ing induction of

labour

Self-hypno-

sis or hypnother-

apy versus con-

trol (standard

childbirth prepa-

ra-

tion; a relaxation

tape; supportive

counselling; psy-

chotherapy)

(7 studies, 1070

women)

Hypnosis & au-

dio

CD versus audio

CD of hypno-

sis (1 study, 297

women)

N.B. one study,

n

= 448, included

three arms and so

data for the dif-

ferent arms are

included in the

separate compar-

isons

• Pain

intensity

• Satisfaction

with pain relief

• Satisfaction

with childbirth

experience

• Breastfeeding

• Assisted

vaginal birth

• Caesarean

section

• Admission

to special care

baby unit/

neonatal

intensive care

• Apgar score

less than seven

at five minutes

• Adverse

effects for

women and

infants

(postnatal

depression,

newborn

resuscitation)

Se-

quence genera-

tion: 2 studies

low risk; 5 stud-

ies unclear risk

Allocation con-

cealment: 1

study low risk; 2

studies high risk;

4 studies unclear

risk

Blinding

(participants &

clinical staff ): 3

studies low risk;

4 studies unclear

risk

Blinding (out-

come assessors)

: 3 studies low

risk; 4 studies

unclear risk

Incomplete

outcome re-

porting: 3 stud-

ies low risk; 2

studies high risk;

2 studies unclear

risk

Selec-

tive outcome re-

porting: 3 stud-

ies low risk; 2

studies high risk;



Table 2. Characteristics of included Cochrane systematic reviews - non-pharmacological interventions (Continued)

2 studies unclear

risk

Other potential

threats to va-

lidity: 3 studies

low risk; 4 stud-

ies unclear risk

Biofeedback

for pain during

labour (Barragán

2011)

20 March 2011 4 stud-

ies in 3 coun-

tries (UK, USA

and Italy) be-

tween 1978 and

2000

(201 women

ran-

domised, 2 stud-

ies (103 women)

contributed data

to meta-analysis)

Women with low

risk pregnan-

cies e.g. healthy

pregnant women

likely to have a

normal birth

Biofeedback ver-

sus no biofeed-

back/stan-

dard care (2 stud-

ies, 103 women)

• Assisted

vaginal birth

• Caesarean

section

Sequence gen-

eration: 1 study

low risk; 3 stud-

ies unclear risk

Allocation con-

cealment:

4 studies unclear

risk

Blinding:

4 studies unclear

risk

Incomplete

outcome re-

porting: 2 stud-

ies low risk; 2

studies high risk

Selec-

tive outcome re-

porting: 1 study

low risk; 3 stud-

ies high risk

Other potential

threats to valid-

ity: 4 studies low

risk

Intracutaneous

or subcutaneous

sterile water in-

jection for pain

management in

labour (Derry

2012)

30 May 2011 7 studies in 5

countries

(Sweden,

Denmark, Iran,

Thailand, India)

between 1990

and 2009

(766 women)

Women in active

labour who re-

quested analge-

sia for pain of

moderate to se-

vere

intensity. There

were no restric-

tions relating to

place of birth

or to maternal

parity, risk sta-

tus, age, weight,

length of gesta-

tion, or stage of

Intracuta-

neous sterile wa-

ter injection ver-

sus normal saline

injection (4 stud-

ies, 467 women)

Subcuta-

neous sterile wa-

ter injection ver-

sus normal saline

injection (2 stud-

ies, 200 women)

Intracu-

taneous & sub-

cutaneous ster-

• Assisted

vaginal birth

• Caesarean

section

Se-

quence genera-

tion: 4 studies

low risk; 3 stud-

ies unclear risk

Allocation con-

cealment: 4

studies low risk;

4 studies unclear

risk

Blinding

(participants &

clinical staff ): 5

studies low risk;




labour ile water injec-

tion versus nor-

mal saline injec-

tion (1 study, 99

women)

1 study high risk;

1 study unclear

risk

Blinding (out-

come assessors):

7 studies low risk

Incomplete

outcome re-

porting: 2 stud-

ies low risk; 1

study high risk;

4 studies unclear

risk

Selective out-

come reporting:

4 studies

low risk; 3 stud-

ies unclear risk

Other potential

threats to va-

lidity: 3 studies

high risk; 4 stud-

ies unclear risk

Immer-

sion in water in

labour and birth

(Cluett 2009)

30 June 2011 12 studies in 11

countries (USA,

Canada, UK,

Sweden,

Finland,

Belguim, Iran,

South Africa,

Brazil, Australia)

between 1993

and 2009

(3252 women)

Nul-

liparous or mul-

tiparous women

in labour with

a singleton preg-

nancy, irrespec-

tive of gestation

or labour charac-

teristics

Immersion ver-

sus no immer-

sion in the first

stage of labour

(8 studies, 2826

women)

Immersion ver-

sus

no immersion in

the second stage

of labour (3 stud-

ies, 286 women)

Early versus late

immersion dur-

ing the first stage

of

labour (1 study,

200 women)

N.B. one study,

n = 60, included

data for both first

and second

stages of labour

and so is in-

• Pain

intensity

• Satisfaction

with childbirth

experience

• Breastfeeding

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women

• Adverse

effects for

infants

• Admission

to special care

baby unit/

neonatal

intensive care

unit

• Apgar score

Sequence gen-

eration: 6 stud-

ies low risk; 2

studies high risk;

4 studies unclear

risk

Allocation con-

cealment: 8

studies low risk;

3 studies high

risk; 1 study un-

clear risk

Blinding (par-

ticipants/clini-

cal staff/out-

come assessor):

12 studies high

risk

Incomplete

out-

come reporting:

11 studies low

risk; 1 study un-




cluded in num-

bers for both

comparisons

less than seven

at five minutes

clear risk

Selective out-

come reporting:

10 studies low

risk; 1 study high

risk; 1 study un-

clear risk

Other potential

threats to valid-

ity: 1 study low

risk; 11 studies

unclear risk

Aromatherapy

for pain manage-

ment in labour (

Smith 2011c)

31 October

2010

2 stud-

ies in 2 coun-

tries (Italy, New

Zealand) be-

tween 2000 and

2007

(535 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Aromatherapy

versus standard

care (1 study,

513 women)

One type of aro-

matherapy (gin-

ger) versus a dif-

ferent type

of aromatherapy

(lemon grass) (1

study, 22

women)

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women

(postpartum

haemorrhage)

• Admission

to special care

baby unit

• Apgar score

less than seven

at five minutes

Sequence gen-

eration: 2 stud-

ies low risk

Allocation con-

cealment: 2

studies low risk

Blinding: 1

study low risk; 1

study high risk

Incomplete

out-

come reporting:

2 studies low risk

Selective out-

come reporting:

2 studies unclear

risk

Other potential

threats to valid-

ity: 1 study low

risk; 1 study high

risk

Relaxation tech-

niques for pain

management in

labour (Smith

2011b)

30 November

2010

11 stud-

ies in 9 countries

(USA, UK, Swe-

den, Italy,

Turkey, Thai-

land, Iran, Tai-

wan, Brazil) be-

tween 1965 and

2010

(1574 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Relaxation (pro-

gres-

sive muscle re-

laxation; breath-

ing; psychopro-

phylaxis) versus

standard care (6

studies,1147

women)

Yoga versus stan-

dard care (2 stud-

ies, 270 women)

Music ver-

• Pain

intensity

• Satisfaction

with pain relief

• Satisfaction

with childbirth

experience

• Assisted

vaginal delivery

• Caesarean

section

• Apgar score

less than seven

Se-

quence genera-

tion: 6 studies

low risk; 5 stud-

ies unclear risk

Allocation con-

cealment: 3

studies low risk;

8 studies unclear

risk

Blinding: 8

studies high risk;

3 studies unclear




sus standard care

(2 studies, 133

women)

Audio-analgesia

versus standard

care (1 study, 24

women)

at five minutes risk

Incomplete

outcome re-

porting: 5 stud-

ies low risk; 2

studies high risk;

4 studies unclear

risk

Selec-

tive outcome re-

porting: 1 study

low risk; 10 stud-

ies unclear risk

Other potential

threats to va-

lidity: 5 studies

low risk; 6 stud-

ies unclear risk

Acupuncture or

acupressure

for pain manage-

ment in labour (

Smith 2011a)

31 October

2010

13 studies in 8

countries (Nor-

way, Sweden,

Denmark, India,

Korea, Taiwan,

China, Iran) be-

tween 2002 and

2010

(1986 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Acupuncture or

acupressure ver-

sus placebo/stan-

dard care/

no treatment (12

studies, 1858

women)

Acupunc-

ture versus ster-

ile water injec-

tion (1 study,

128 women)

• Pain

Intensity

• Satisfaction

with pain relief

• Satisfaction

with childbirth

experience

• Assisted

vaginal birth

• Caesarean

section

• Apgar score

less than seven

at five minutes

Se-

quence genera-

tion: 12 studies

low risk; 1 study

unclear risk

Allocation con-

cealment: 9

studies low risk;

4 studies unclear

risk

Blinding: 3

studies low risk;

5 studies high

risk; 5 studies

unclear risk

Incomplete

outcome re-

porting: 9 stud-

ies low risk; 1

study high risk;

3 studies unclear

risk

Selective out-

come reporting:

13 studies un-

clear risk

Other potential

threats to valid-




ity: 8 studies low

risk; 3 studies

high risk; 2 stud-

ies unclear risk

Massage, reflex-

ology and other

manual methods

for pain manage-

ment in labour (

Smith 2012)

30 June 2011 6 stud-

ies in 4 countries

(USA, UK, Iran,

Taiwan) between

1997 and 2010

(401 women

ran-

domised, 5 stud-

ies (326 women)

contributed data

to meta-analysis)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Massage

versus usual care

(4 studies, 225)

Massage ver-

sus breathing ex-

ercises (1 study,

28 women)

Mas-

sage versus mu-

sic (1 study, 101

women)

• Pain

intensity

• Satisfaction

with pain relief

• Sense of

control in labour

• Assisted

vaginal birth

• Caesarean

section

• Admission

to neonatal

intensive care

unit

Sequence gen-

eration: 4 stud-

ies low risk; 1

study high risk;

1 study unclear

risk

Allocation con-

cealment:

1 study low risk;

5 studies unclear

risk

Blinding

(participants &

clinical staff ): 5

studies high risk;

1 study unclear

risk

Blinding (out-

come assessor)

: 4 studies low

risk; 1 study high

risk; 1 study un-

clear risk

Incom-

plete outcome

reporting: 5

studies low risk;

1 study unclear

risk

Selective out-

come reporting:

1 study low risk;

5 studies unclear

risk

Other potential

threats to va-

lidity: 3 studies

low risk; 3 stud-

ies unclear risk

Tran-

scutaneous elec-

trical nerve stim-

ulation (TENS)

for pain manage-

30 April 2011 17 studies in 15

countries (USA,

Canada, UK,

Ireland, France,

Swe-

Women in

labour (risk not

stated)

TENS versus

placebo or usual

care (17 studies,

1455 women)

• Pain

intensity

• Satisfaction

with pain relief

Sequence gen-

eration: 3 stud-

ies low risk; 1

study high risk;




ment in labour (

Dowswell 2009)

den, Denmark,

Germany, Nor-

way, the Nether-

lands, India, Tai-

wan, China,

Brazil, Australia)

between 1978

and 2010

(1466 women)

TENS versus

sterile water in-

jection (1 study,

22 women)

• Assisted

vaginal birth

• Caesarean

section

• Side effects

for baby

14 studies un-

clear risk

Allocation con-

cealment: 3

studies low risk;

1 study high risk;

14 studies un-

clear risk

Blinding

(participants): 8

studies high risk;

10 studies un-

clear risk

Blinding (clini-

cal staff )

: 8 studies high

risk; 10 studies

unclear risk

Blinding (out-

come assessor)

: 7 studies high

risk; 11 studies

unclear risk

Incomplete

out-

come reporting:

10 studies low

risk; 2 studies

high risk; 6 stud-

ies unclear risk

Other potential

threats to valid-

ity: 18 studies

unclear risk

N.B. 17 studies

contributed data

to the review, but

18 studies were

included and as-

sessed for risk of

bias



Table 3. Characteristics of included Cochrane systematic reviews - pharmacological interventions

Review title Date of search No. Studies in-

cluded

(No. Patients in

included stud-

ies)

Inclusion crite-

ria for “Types of

participants”

Comparison in-

terventions (no.

studies)

Outcomes for

which data were

reported

that could be

included in an

analysis

Summary

of quality of evi-

dence in reviews

(risk of bias)

Inhaled analgesia

for pain manage-

ment in labour (

Klomp 2012)

7 September

2011

26 studies in 8

countries (USA,

Canada, UK,

Sweden, Nor-

way, China, Sin-

gapore, Iran) be-

tween 1969 and

2009

(2967 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Inhaled analgesia

versus placebo

control/no treat-

ment (9 studies,

1495 women)

Inhaled analge-

sia versus a dif-

ferent type of

inhaled analgesia

(14 studies, 752

women)

Inhaled analgesia

of one strength

versus a different

strength (2 stud-

ies, 625 women)

Inhaled analgesia

using one type of

delivery system

versus a different

system (2 stud-

ies, 75 women)

Inhaled analgesia

versus TENS (1

study, 20

women)

• Pain

Intensity

• Satisfaction

with pain relief

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women (nausea;

vomiting;

drowsiness;

dizziness; blood

loss; pre-

eclampsia)

• Adverse

effects for

infants

(hypoxaemia;

neuro-

behavioural

score; neonatal

asphyxia)

• Admission

to special care

baby unit

• Apgar score

less than seven

at five minutes

Se-

quence genera-

tion: 7 studies

low risk; 19 stud-

ies unclear risk

Allocation con-

ceal-

ment: 3 studies

low risk; 23 stud-

ies unclear risk

Blinding

(participants &

clinical staff ): 3

studies low risk;

4 studies high

risk; 19 studies

unclear risk

Blinding (out-

come as-

sessor): 3 stud-

ies low risk; 4

studies high risk;

19 studies un-

clear risk

Incomplete

out-

come reporting:

13 studies low

risk; 4 studies

high risk; 9 stud-

ies unclear risk

Selective out-

come reporting:

16 studies low

risk; 5 studies

high risk; 5 stud-

ies unclear risk

Other potential



Table 3. Characteristics of included Cochrane systematic reviews - pharmacological interventions (Continued)

threats to va-

lidity: 6 stud-

ies low risk; 3

studies high risk;

17 studies un-

clear risk

Parenteral opi-

oids for mater-

nal pain manage-

ment in labour (

Ullman 2010)

30 April

2011

57 studies in 21

countries (USA,

Canada, UK,

Italy,

Austria, Sweden,

Norway, Den-

mak, Germany,

the Netherlands,

Turkey, Ar-

gentina, Brazil,

India, China,

Hong Kong, Sin-

gapore,

Thailand, South

Africa,

Egypt, Iran) be-

tween 1958 and

2010

(7000 women)

Women in

labour. Studies

focusing specifi-

cally and exclu-

sively on women

in

high-risk groups,

or women in pre-

mature labour

(before 37 weeks’

gestation) were

excluded. Stud-

ies which include

such women as

part of a broader

sample were in-

cluded

Intramuscu-

lar (IM) opioid

comparisons

16 comparisons

(37 studies)

Intravenous (IV)

opioid compar-

isons

7 comparisons

(10 studies)

Intravenous pa-

tient controlled

opioids (IV

PCA)

5 comparisons (7

studies)

Opi-

oids versus tran-

scutaneous elec-

trical nerve stim-

ulation(TENS)

1 comparison (3

studies)

• Pain

Intensity

• Satisfaction

with pain relief

• Satisfaction

with childbirth

experience

• Breastfeeding

problems

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women (nausea

& vomiting;

sleepiness;

drowsiness;

blood loss)

• Adverse

effects for

infants

(resuscitation;

fetal heart rate

changes;

respiratory

distress;

neonatal neuro-

behavioural

score; ventilator

support)

• Admission

to special care

baby unit

• Apgar score

less than seven

at five minutes

Sequence gen-

eration: 13 stud-

ies low risk; 1

study high risk;

43 studies un-

clear risk

Allocation con-

ceal-

ment: 17 studies

low risk; 40 stud-

ies unclear risk

Blinding (par-

tic-

ipants): 22 stud-

ies low risk; 6

studies high risk;

29 studies un-

clear risk

Blinding (clin-

ical staff ): 22

studies low risk;

6 studies high

risk; 29 studies

unclear risk

Blinding (out-

come assessor):

17

study low risk; 5

studies high risk;

35 studies un-

clear risk

Incom-

plete outcome

reporting: 21

studies low risk;

19 studies high

risk; 17 studies

unclear risk

Selec-




tive outcome re-

porting: 1 stud-

ies low risk; 3

studies high risk;

53 studies un-

clear risk

Other potential

threats to va-

lidity: 11 stud-

ies low risk; 2

studies high risk;

44 studies un-

clear risk

Non-opioid

drugs for pain

management in

labour (Othman

2012)

19 May 2011 18 studies in 7

countries (USA,

Canada,

UK, Sweden, Ar-

gentina, In-

dia, China) be-

tween 1963 and

2004

(2733 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Non-

opioid drug ver-

sus placebo or no

treatment

(14 studies, 2003

women)

Non-opioid

drug versus any

other pain man-

agement

intervention e.g.

opioids (3 stud-

ies, 563 women)

Non-opioid

drug versus dif-

ferent non-opi-

oid drug (2 stud-

ies, 562 women)

Non-

opioid drug ver-

sus same non-

opioid different

dose (1 study, 28

women)

(3 studies have

more than two

arms and are in-

cluded in more

than one com-

parison group)

• Pain

intensity

• Satisfaction

with pain relief

• Satisfaction

with childbirth

experience

• Breastfeeding

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women

• Adverse

effects for

infants

• Apgar score

less than seven

at five minutes

Se-

quence genera-

tion: 6 studies

low risk; 12 stud-

ies unclear risk

Allocation con-

ceal-

ment: 5 studies

low risk; 13 stud-

ies unclear risk

Blinding (par-

ticipants/clin-

ical staff ): 14

studies low risk;

4 studies unclear

risk

Blinding (out-

come assessor)

: 3 studies low

risk; 15 studies

unclear risk

Incomplete

out-

come reporting:

16 studies low

risk; 2 studies

high risk

Selective out-

come reporting:

12 studies low

risk; 5 studies

high risk; 1 study




unclear risk

Other potential

threats to valid-

ity: 13 studies

low risk; 1 study

high risk; 4 stud-

ies unclear risk

Local anaesthetic

nerve block

for pain manage-

ment in labour (

Novikova 2012)

6 June 2011 12 studies (coun-

tries not stated in

review) between

1969 and 2009

(1549 women)

Women in

labour, in-

cluding high risk

groups e.g.

preterm

labour or follow-

ing induction

Local anaesthetic

nerve block ver-

sus differ-

ent dose/agent or

timing of anaes-

thetic nerve

block (8 studies,

1120 women)

Local anaesthetic

nerve block ver-

sus

placebo (1 study,

200 women)

Local anaesthetic

nerve block ver-

sus

opioid (2 studies,

129 women)

Local anaesthetic

nerve block ver-

sus non-opi-

oid (1 study, 100

women)

• Satisfaction

with pain relief

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women

• Apgar score

less than seven

at five minutes

Sequence gen-

eration: 2 stud-

ies low risk; 2

studies high risk;

8 studies unclear

risk

Allocation con-

cealment:

1 study high risk;

11 studies un-

clear risk

Blinding (par-

ticipants/

clinical staff ): 4

studies low risk;

4 studies high

risk; 4 studies

unclear risk

Blinding (out-

come assessor)

: 4 studies low

risk; 5 studies

high risk; 3 stud-

ies unclear risk

Incomplete

outcome re-

porting: 6 stud-

ies low risk; 4

studies high risk;

2 studies unclear

risk

Selec-

tive outcome re-

porting: 5 stud-

ies low risk; 7

studies high risk

Other potential

threats to va-

lidity: 9 studies

low risk; 3 stud-

ies high risk




Epidural ver-

sus non-epidural

or no analgesia

in labour (Anim-

Somuah 2011)

31 March 2011 38 studies in 18

countries (USA,

Canada, UK,

France, Sweden,

Fin-

land, Denmark,

Mexico, Russia,

Saudi Ara-

bia, Egypt, Is-

rael, Iran, India,

Taiwan, Thai-

land, China,

Australia) be-

tween 1974 and

2010

(9658 women)

Pregnant women

in

labour request-

ing pain relief,

regardless of par-

ity and whether

labour was spon-

taneous or in-

duced

Epidu-

ral versus opioids

(33 studies, 8868

women)

Epidural

versus no anal-

gesia (5 studies,

790 women)

• Pain

intensity

• Satisfaction

with pain relief

• Sense of

control in labour

• Satisfaction

with childbirth

experience

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women (long-

term backache;

maternal

hypotension;

postnatal

depression;

motor blockade;

headache;

nausea and

vomiting;

itching; fever;

shivering;

drowsiness;

urinary

retention;

malposition;

surgical

amniotomy)

• Adverse

effects for

infants (acidosis;

naloxone

administration;

meconium

staining of

liquor)

• Admission

to special care

baby unit

• Apgar score

Sequence gen-

eration: 18 stud-

ies low risk; 1

study high risk;

19 studies un-

clear risk

Allocation con-

ceal-

ment: 16 studies

low risk; 22 stud-

ies unclear risk

Blinding

(participants): 4

studies low risk;

6 studies high

risk; 28 studies

unclear risk

Blinding (clini-

cal staff ): 4

studies low risk;

3 studies high

risk; 31 studies

unclear risk

Blinding (out-

come assessor):

1 study low risk;

1 study high risk;

36 studies un-

clear risk

Incom-

plete outcome

reporting: 12

studies low risk;

7 studies high

risk; 19 studies

unclear risk

Selective out-

come reporting:

14 study low

risk; 15 studies

high risk; 9 stud-

ies unclear risk

Other potential

threats to va-




of less than

seven at five

minutes

lidity: 18 stud-

ies low risk; 8

studies high risk;

12 studies un-

clear risk

Combined

spinal- epidu-

ral (CSE) versus

epidural analge-

sia in labour (

Simmons 2012)

28 September

2011

27 studies in 9

countries (USA,

Canada, UK,

France, Italy,

Belguim, Spain,

Saudi Ara-

bia, Brazil) be-

tween 1991 and

2009

(3303 women)

Women having

combined

spinal-epidural

or epidural anal-

ge-

sia commenced

during the first

stage of labour

CSE versus tra-

ditional epidural

CSE versus low-

dose epidural

• Pain

intensity

• Satisfaction

with pain relief

• Assisted

vaginal birth

• Caesarean

section

• Adverse

effects for

women and

infants

• Admission

to special care

baby unit/

neonatal

intensive care

unit

• Apgar score

less than seven

at five minutes

Se-

quence genera-

tion: 11 studies

low risk; 16 stud-

ies unclear risk

Allocation con-

ceal-

ment: 14 studies

low risk; 13 stud-

ies unclear risk

Blinding (par-

ticipants/staff/

asses-

sors): 15 stud-

ies low risk; 3

studies high risk;

9 studies unclear

risk

Incomplete

out-

come reporting:

25 studies low

risk; 1 study high

risk; 1 study un-

clear risk

Selective out-

come reporting:

23 studies low

risk; 4 studies

unclear risk

Other potential

threats to va-

lidity: 3 studies

low risk; 4 stud-

ies unclear risk

(20 studies not

assessed)



Table 4. Characteristics of included non-Cochrane systematic reviews - non-pharmacological

Review title Date of search No. studies in-

cluded

Inclusion crite-

ria for “Types of

participants”

Comparison in-

terventions (no.

studies)

Outcomes for

which data were

reported

that could be

included in an

analysis

Summary

of quality of evi-

dence in reviews

(risk of bias)

Sterile water in-

jec-

tion for labour

pain: a system-

atic review and

meta-analysis of

randomised con-

trolled trials

(Hutton 2009)

Up to 2009 8 (783 women) Pregnant women

who had lower

back pain during

the active stage

of labour and re-

quested pain

medication

Intra-

cutaneous sterile

or subcutaneous

sterile water in-

jection versus

placebo control

(saline) or an-

other non-phar-

ma-

cological modal-

ity (acupuncture;

TENs) (8 stud-

ies, 783 women)

• Pain

intensity

• Caesarean

section

Methodological

quality assessed

using the modi-

fied Jadad scale

Score of 10 or

more = consid-

ered high quality

score 8: 1 study

score 10: 4 stud-

ies

score 12: 2 stud-

ies

score 13: 1 study

Table 5. Characteristics of included non-Cochrane systematic reviews - pharmacological

Review title Date of search No. studies in-

cluded

Inclusion crite-

ria for “Types of

participants”

Comparison in-

terventions (no.

studies)

Outcomes for

which data were

reported

that could be

included in an

analysis

Summary

of quality of evi-

dence in reviews

(risk of bias)

Epidural ropiva-

caine ver-

sus bupivacaine

for labor: a meta-

analysis

(Halpern 2003a)

15 March 2002 23 studies

(2074 women)

Labouring

women

Ropivacaine ver-

sus bupivacaine

(23 studies, 2074

women)

• Pain

intensity (time

to onset of

analgesia)

• Satisfaction

with pain relief

(numbers with

“excellent

analgesia”)

• Assisted

vaginal birth

• Caesarean

section

• Side effects

for mother

As-

sessed the quality

of studies using

the Jadad quality

index score. This

scale has a maxi-

mum of 5 points.

Studie are con-

sid-

ered high quality

if the score is 3 or

more

Score of 5: 4

studies



Table 5. Characteristics of included non-Cochrane systematic reviews - pharmacological (Continued)

(hypotension;

nausea or

vomiting)

• Apgar score

less than seven

at five minutes

Score of 4: 8

studies

Score of 3: 5

studies

Score of 2: 1

study

NA (not applica-

ble): 4 studies

1 study unpub-

lished data and

so not assessed

Fetal bradycardia

due to intrathe-

cal opioids for

labour analgesia:

a systematic re-

view

(Mardirosoff

2002)

25 January 2001 24 studies (3513

women)

Labouring

women

Any in-

trathecal opioid

with or without

local anaesthetic

versus any anal-

gesic regimen

that excluded in-

trathecal opioids

(24 studies, 3513

women)

• Assisted

vaginal birth

• Casaerean

section

• Side effects

for mother

(pruritus)

• Side effects

for baby (fetal

heart rate

abnormalities;

fetal

bradycardia)

• Apgar score

less than seven

at five minutes

Assessed

adequacy of ran-

domi-

sation; blinding;

and description

of withdrawals,

according to a

5-point Oxford

scale

Median

quality score was

3.5 (range 1 to 5)

Table 6. Quality of evidence in included Cochrane systematic reviews - non-pharmacological interventions

Review Title Sequence gen-

eration assessed

(% studies low

risk)

Allocation

concealment as-

sessed

(% studies low

risk)

Blinding of par-

ticipants, per-

sonnel and out-

come assessors

assessed

(% studies low

risk)

Incom-

plete outcome

data assessed

(% studies low

risk)

Selec-

tive outcome re-

porting assessed

(% studies low

risk)

Other potential

threats to valid-

ity assessed

(% studies low

risk)

Hyp-

nosis (7 studies)

(Madden 2012)

2 studies (28%) 1 study (14%) Participants

& Personnel - 3

studies (43%)

Outcome asses-

sors - 3 studies

(43%)

3 studies (43%) 3 studies (43%) 3 studies (43%)

Biofeed-

back (4 studies)

(Barragán 2011)

1 study (25%) 0 studies (0%) 0 studies (0%) 2 studies (50%) 1 study (25%) 4 studies (100%)



Table 6. Quality of evidence in included Cochrane systematic reviews - non-pharmacological interventions (Continued)

Intracutaneous/

subcuta-

neous sterile wa-

ter injection (7

studies) (Derry

2012)

4 studies (57%) 4 studies (57%) Participants

& Personnel - 5

studies (71%)

Outcome asses-

sors - 7 studies

(100%)


Immer-

sion in water (12

studies) (Cluett

2009)

6 studies (50%) 8 studies (67%) 0 studies (0%) 11 studies (92%) 10 studies (83%) 1 study (8%)

Aromather-

apy (2 studies) (

Smith 2011c)

2 studies (100%) 2 studies (100%) 1 study (50%) 2 studies (100%) 0 studies (0%) 1 study (50%)

Relaxation tech-

niques (11 stud-

ies) (Smith

2011b)

6 studies (54%) 3 studies (27%) 0 studies (0%) 5 studies (45%) 1 study (9%) 5 studies (45%)

Acupuncture (13

studies) (Smith

2011a)

12 studies (92%) 9 studies (69%) 3 studies (23%) 9 studies (69%) 0 studies (0%) 8 studies (62%)

Mas-

sage, reflexology

and other man-

ual methods (6

studies) (Smith

2012)

4 studies (67%) 1 study (17%) Participants

& Personnel - 0

studies (0%)

Outcome asses-

sors - 4 studies

(67%)

5 studies (83%) 1 study (17%) 3 studies (50%)

TENS (18 stud-

ies) (Dowswell

2009)

3 studies (17%) 3 studies (17%) 0 studies (0%) 10 studies (56%) No - NOT AS-

SESSED

0 studies (0%)

Table 7. Quality of evidence in included Cochrane systematic reviews - pharmacological interventions

Review Title Sequence gen-

eration assessed

(% studies low

risk)

Allocation

concealment as-

sessed

(% studies low

risk)

Blinding of par-

ticipants, per-

sonnel and out-

come assessors

assessed

(% studies low

risk)

Incom-

plete outcome

data assessed

(% studies low

risk)

Selec-

tive outcome re-

porting assessed

(% studies low

risk)

Other potential

threats to valid-

ity assessed

(% studies low

risk)



Table 7. Quality of evidence in included Cochrane systematic reviews - pharmacological interventions (Continued)

Inhaled analge-

sia (26 studies) (

Klomp 2012)

7 studies (27%) 3 studies (12%) Participants/Per-

sonnel - 3 studies

(12%)

Outcome asses-

sors - 3 studies

(12%)


Parenteral opi-

oids for mater-

nal pain manage-

ment in labour

(57 studies)

(Ullman 2010)

13 studies (23%) 17 studies (30%) Participants - 22

studies (39%)

Personnel - 22

studies (39%)

Outcome asses-

sors - 17 studies

(30%)

21 studies (37%) 1 study (2%) 11 studies (19%)

Non-opioid

drugs (18 stud-

ies) (Othman

2012)


sonnel - 14 stud-

ies (78%)

Outcome asses-

sors - 3 studies

(17%)


Local anaesthetic

nerve blocks (12

studies)

(Novikova 2012)


sonnel - 4 studies

(34%)

Outcome asses-

sors - 4 studies

(34%)


Epidu-

ral (38 studies)

(Anim-Somuah

2011)

18 studies (47%) 16 studies (42%) Participants - 4

studies (11%)

Personnel - 4

studies (11%)

Outcome asses-

sors - 1 study

(3%)


Combined

spinal epidu-

ral (27 studies) (

Simmons 2012)

11 studies (41%) 14 studies (52%) 15 studies (56%) 25 studies (93%) 23 studies (85%) 3 studies (11%)

N.B. 20 stud-

ies not assessed

(74%)



Table 8. Quality of evidence in included non-Cochrane systematic reviews - non-pharmacological

Review Title Summary of quality of evidence in reviews (risk of bias)

Sterile water injection for labour pain: a systematic review and

meta-analysis of randomised controlled trials

(Hutton 2009)

Methodological quality assessed using the modified Jadad scale

Score of 10 or more = considered high quality

score 8: 1 study

score 10: 4 studies

score 12: 2 studies

score 13: 1 study

Table 9. Quality of evidence in included non-Cochrane systematic reviews - pharmacological

Review Title Summary of quality of evidence in reviews (risk of bias)

Epidural ropivacaine versus bupivacaine for labor: a meta-analysis

(Halpern 2003a)

Assessed the quality of studies using the Jadad quality index score.

This scale has a maximum of 5 points. Studie are considered high

quality if the score is 3 or more

Score of 5: 4 studies



Score of 2: 1 study

NA (not applicable): 4 studies

1 study unpublished data and so not assessed

Fetal bradycardia due to intrathecal opioids for labour analgesia:

a systematic review

(Mardirosoff 2002)

Assessed adequacy of randomisation; blinding; and description of

withdrawals, according to a 5-point Oxford scale

Median quality score was 3.5 (range 1 to 5)

Table 10. AMSTAR ratings for each Cochrane systematic review - non-pharmacological interventions

AMSTAR

criteria

Hypnosis

(Madden

2012)

Biofeed-

back

(Barragán

2011)

Intracuta-

neous/

subcuta-

neous

sterile wa-

ter

injection (

Derry

2012)

Immer-

sion in

wa-

ter (Cluett

2009)

Aro-

mather-

apy (Smith

2011c)

Relax-

ation

tech-

niques

(Smith

2011b)

Acupunc-

ture or

acu-

pressure (

Smith

2011a)

Massage,

reflex-

ology and

other

man-

ual meth-

ods (Smith

2012)

TENS

(Dowswell

2009)

A priori

design

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Dupli-

cate selec-

tion & ex-

traction




Table 10. AMSTAR ratings for each Cochrane systematic review - non-pharmacological interventions (Continued)

Compre-

hensive lit-

erature

search


Searched

for reports

regardless

of publica-

tion

type or lan-

guage


Excluded/

In-

cluded list

provided


Character-

istics of in-

cluded

studies

provided


Quality as-

sess-

ment of in-

cluded

studies

assessed &

presented


Qual-

ity used ap-

propriately

in formu-

lating con-

clusions


Meth-

ods used to

combine

studies ap-

propriate

Yes Yes Yes Yes Not appli-

cable

Yes Yes Yes Yes

Publi-

cation bias

assessed

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable

Not appli-

cable



Table 10. AMSTAR ratings for each Cochrane systematic review - non-pharmacological interventions (Continued)

Conflict of

interest

stated


Total

score (out

of a maxi-

mum of

11)

10 10 10 10 9 10 10 10 10

Table 11. AMSTAR ratings for each Cochrane systematic review - pharmacological interventions

AMSTAR crite-

ria

Inhaled analge-

sia (Klomp

2012)

Opioids

(Ullman 2010)

Non-opioid

drugs (Othman

2012)

Lo-

cal anaesthetic

nerve blocks (

Novikova 2012)

Epidural

(Anim-Somuah

2011)

Combined

spinal epidural

(Simmons 2012)

A priori design Yes Yes Yes Yes Yes Yes

Duplicate selec-

tion & extrac-

tion

Yes Yes Yes Yes Yes Yes

Comprehensive

literature search


Searched for re-

ports re-

gardless of pub-

lication type or

language


Excluded/

Included list pro-

vided


Character-

istics of included

studies provided


Qual-

ity assessment of

included studies

assessed & pre-

sented




Table 11. AMSTAR ratings for each Cochrane systematic review - pharmacological interventions (Continued)

Quality used ap-

propriately in

formulating con-

clusions


Methods used to

combine studies

appropriate


Publication bias

assessed

Not applicable

(too few studies

for each outcome

within different

comparisons)

Not applicable

(too few studies

for each outcome

within different

comparisons)

Not applicable

(too few studies

for each outcome

within different

comparisons)

Not applicable

(too few studies

for each outcome

within different

comparisons)

No No

Conflict of inter-

est stated


Total score (out

of a maximum

of 11)

10 10 10 10 10 10

Table 12. AMSTAR ratings for each non-Cochrane systematic review

AMSTAR cri-

teria

Epidural ropi-

vacaine versus

bupi-

vacaine for la-

bor: a meta-

analysis

(Halpern

2003a)

Fetal brady-

cardia due to

intrathe-

cal opioids for

labour analge-

sia: a system-

atic review

(Mardirosoff

2002)

Ster-

ile water injec-

tion for labour

pain: a system-

atic review and

meta-analysis

of randomised

controlled tri-

als

(Hutton

2009)

A priori design Cannot tell Cannot tell Cannot tell

Duplicate se-

lection & ex-

traction

Yes Yes Yes

Com-

prehensive lit-

erature search

Yes Yes Yes



Table 12. AMSTAR ratings for each non-Cochrane systematic review (Continued)

Searched for

reports regard-

less of publi-

cation type or

language

No (limited to

English

language pub-

lications)

Yes Yes

Excluded/

Included list

provided

No

(only included

studies)

Yes Yes

Charac-

teristics of in-

cluded studies

provided

Yes Yes Yes

Quality assess-

ment of

included stud-

ies assessed &

presented

Yes Yes Yes

Quality

used appropri-

ately in for-

mulating con-

clusions

No Cannot tell Cannot tell

Methods used

to combine

studies appro-

priate

Yes Yes Yes

Publication

bias assessed

No No No

Conflict of in-

terest stated

No No Yes

Total score

(out of a max-

imum of 11)

4 7 8



Table 13. (1.) Results by individual review - hypnosis

1. Hypnosis for pain management during labour and childbirth, 7 studies, 1213 women (Madden 2012)

1.1. Hypnosis versus no hyp-

nosis/standard care (7 studies,

1070 women)

Outcome No. of studies (no. women) Results

Pain intensity Outcome only reported for one

quasi-RCT (60 women)

Satisfaction with pain relief 1 (264) RR 1.06, 95% CI 0.94 to 1.20,

no evidence of a significant dif-

ference

Sense of control in labour Outcome not reported

Satisfaction with childbirth ex-

perience

2 (370) average RR 1.36, 95% CI 0.52 to

3.59, no evidence of a significant

difference

Effect (negative) on mother/

baby interaction

Outcome not reported

Breastfeeding (at discharge -

any breastfeeding)

1 (304) RR 1.00, 95% CI 0.97 to 1.03,


ference

Assisted vaginal birth 3 (414) average RR 0.73, 95% CI 0.36 to


difference

Caesarean section 3 (867) average RR 0.54, 95% CI 0.18 to


difference

Adverse effects for women (post

partum haemorrhage)

1 (305) RR 1.68, 95% CI 0.90 to 3.12,


ference


partum blood transfusion)

1 (305) RR 3.92, 95% CI 0.44 to 34.69,


ference

Adverse effects for women

(postnatal depression)

1 (305) RR 1.17, 95% CI 0.77 to 1.78,


ference

Adverse effects for women (ad-

mission to HDU)

1 (305) RR 1.47, 95% CI 0.25 to 8.68,




Table 13. (1.) Results by individual review - hypnosis (Continued)

ference


(readmission to hospital)

1 (267) RR 1.56, 95% CI 0.62 to 3.90,


ference

Adverse effects for infants (new-

born resuscitation)

1 (520) RR 0.67, 95% CI 0.11 to 3.96,


ference

Adverse effects for infants (read-

mission to hospital)

1 (267) RR 1.39, 95% CI 0.64 to 3.02,


ference

Admission to special care baby

unit/neonatal intensive care

unit

2 (345) average RR 0.58, 95% CI 0.12 to


difference

Apgar score less than seven at

five minutes

1 (305) RR 0.49, 95% CI 0.04 to 5.35,


ference

Poor infant outcomes at long-

term follow-up


Cost Outcome not reported

1.2. One type of hypnosis ver-

sus another type of hypnosis

(1 study, 297 women)


Pain intensity Outcome not reported



ference



perience

1 (297) RR 0.96, 95% CI 0.83 to 1.10,


ference


baby interaction


Breastfeeding (at discharge -

any breastfeeding)

1 (296) RR 0.99, 95% CI 0.97 to 1.02,


ference



Table 13. (1.) Results by individual review - hypnosis (Continued)

Assisted vaginal birth 1 (297) RR 0.85, 95% CI 0.55 to 1.30,


ference

Caesarean section 1 (297) RR 1.41, 95% CI 0.90 to 2.21,


ference


partum haemorrhage)

1 (297) RR 1.01, 95% CI 0.60 to 1.72,


ference


partum blood transfusion)

1 (297) RR 0.53, 95% CI 0.16 to 1.77,


ference



1 (297) RR 1.43, 95% CI 0.90 to 2.27,


ference

Adverse effects for women (ad-

mission to HDU)

1 (297) RR 0.40, 95% CI 0.10 to 1.51,


ference


(readmission to hospital)

1 (267) RR 1.36, 95% CI 0.57 to 3.29,


ference

Adverse effects for infants (read-

mission to hospital)

1 (267) RR 1.54, 95% CI 0.69 to 3.44,


ference



unit

1 (297) RR 1.09, 95% CI 0.79 to 1.51,


ference


five minutes

1 (297) RR 0.93, 95% CI 0.06 to 14.71,


ference


term follow-up



I2 values reported in table only when random effects analysis has been carried out due to substantial heterogeneity indicated by an I2

value greater than 30%

CI: confidence interval; RCT: randomised controled trial; RR: risk ratio



Table 14. (2.) Results by individual review - biofeedback

2. Biofeedback for pain management during labour, 4 studies, 201 women (Barragán 2011)

2.1. Biofeedback versus no

biofeedback/standard care


Pain intensity 3 (193) Data could not be included in

analysis: no data provided for the

control group in one study; data

reported only in a figure in one

study; no numerical data pro-

vided in one study, described nar-

ratively

Satisfaction with pain relief 1 (55) No data provided for the control

group, so data could not be anal-

ysed

Sense of control in labour 1 (55) No data provided for the control

group, so data could not be anal-

ysed


perience



baby interaction


Breastfeeding Outcome not reported

Assisted vaginal birth 2 (103) Average RR 0.75, 95% CI 0.18

to 3.10 (random effects; hetero-

geneity: I2 = 80%, Tau2 = 0.86,

Chi2 test for heterogeneity P = 0.

02), no evidence of a significant

difference



ference

Adverse effects Outcome not reported



unit



five minutes

2 (103) Mean values reported without

standard deviations.



Table 14. (2.) Results by individual review - biofeedback (Continued)


term follow-up





CI: confidence interval; RR: risk ratio

Table 15. (3.) Results by individual review - sterile water

3. Intracutaneous or subcutaneous sterile water injection compared with blinded controls for pain management in labour, 7

studies, 766 women (Derry 2012)

3.1.Sterile water injection ver-

sus placebo


Intracutaneous sterile water in-

jection versus placebo

Pain intensity Outcome not reported in a suit-

able format

Subcutaneous sterile water in-


Pain intensity Outcome not reported in a suit-

able format

Satisfaction with pain relief Outcome not reported



perience



baby interaction




no significant difference between

groups



groups

Intracutaneous sterile water in-


Adverse effects for women -

pain at injection site

1 (62) Outcome data not analysed



Table 15. (3.) Results by individual review - sterile water (Continued)

Subcutaneous sterile water in-


Adverse effects for women -

pain at injection site

1 (62) Outcome data not analysed

Adverse effects for infant Outcome not reported

Admission to neonatal intensive

care unit



five minutes

Outcome not reported in this for-

mat


term follow-up






Table 16. (4.) Results by individual review - immersion in water

4. Immersion in water in labour and birth, 12 studies, 3252 women (Cluett 2009)

4.1. Immersion versus no im-

mersion in the first stage

of labour (10 studies, 2932

women)


Pain intensity - mean visual ana-

logue pain scores (VAS) at the

start of assessment period

2 (141) MD -0.01, 95% CI -0.54 to 0.

52, no difference between groups

in pain intensity

Pain intensity - mean visual ana-

logue pain scores (VAS) up to

one hour after the start of as-

sessment

2 (141) MD -0.81, 95% CI -1.34 to -0.


in pain intensity

Pain intensity - Ordinal descrip-

tion as moderate to severe, 30

mins after randomisation

1 (120) RR 0.75, 95% CI 0.62 to 0.

91, significantly fewer women

in the immersion group experi-

enced moderate to severe pain

Pain intensity - VAS scale 8 to

10, 30 mins after randomisa-

tion

1 (120) RR 0.72, 95% CI 0.58 to 0.90,

significantly fewer women in the

immersion group had VAS score



Table 16. (4.) Results by individual review - immersion in water (Continued)

of 8 to 10

Pain intensity - Ordinal scale

pain faces 4 to 5, 30 mins after

randomisation

1 (120) RR 0.67, 95% CI 0.51 to 0.90,


immersion group had pain faces

4 to 5 on pain scale


tion as moderate to severe, 1 hr

after randomisation

1 (117) RR 0.76, 95% CI 0.63 to 0.





10, 1 hr after randomisation

1 (117) RR 1.21, 95% CI 0.69 to 2.11,


ference between groups


pain faces 4 to 5, 1 hr after ran-

domisation

1 (117) RR 0.68, 95% CI 0.53 to 0.86,





tion as moderate to severe, 2 hrs

after randomisation

1 (57) 0.76, 95% CI 0.59 to 0.98, sig-

nificantly fewer women in the

immersion group experienced

moderate to severe pain


10, 2 hrs after randomisation

1 (57) RR 0.83, 95% CI 0.66 to 1.05,



Pain intensity -Ordinal scale

pain faces 4 to 5, 2 hrs after ran-

domisation

1 (57) RR 0.72, 95% CI 0.52 to 0.98,

significantly fewer women in im-

mersion group had pain faces 4

to 5 on pain scale


tion as moderate to severe, 3 hrs

after randomisation

1 (32) RR 0.52, 95% CI 0.23 to 1.16,





1 (32) RR 0.69, 95% CI 0.39 to 1.23,







pain faces 4 to 5, 3 hrs after ran-

domisation

1 (32) RR 0.57, 95% CI 0.25 to 1.27,




tion as moderate to severe, 24

hrs after randomisation

1 (119) RR 0.64, 95% CI 0.50 to 0.






1 (119) RR 0.62, 95% CI 0.49 to 0.80,


immersion group had VAS score

of 8 to 10


pain faces 4 to 5, 24 hrs after

randomisation

1 (119) RR 0.69, 95% CI 0.54 to 0.87,




‘ Satisfaction with pain relief Outcome not reported



perience


Effect on mother/baby interac-

tion


Breastfeeding (not breastfeed-

ing after six weeks post delivery)

2 (363) RR 1.17, 95% CI 0.64 to 2.15,










(postpartum haemorrhage)

1 (274) RR 1.58, 95% CI 0.80 to 3.13,




(blood loss - mean blood loss

ml)

2 (153) MD -14.33. 95% CI -63.03 to

34.37, no evidence of a signifi-

cant difference between groups




Adverse effects for women (per-

ineal trauma - episiotomy)

5 (1272) RR 0.93, 95% CI 0.80 to 1.08,




ineal trauma - second-degree

tear)

5 (1286) RR 0.94, 95% CI 0.74 to 1.20,




ineal trauma - third or fourth

degree tear)

5 (2401) RR 1.37, 95% CI 0.86 to 2.17,



Adverse effects for women (sys-

tolic blood pressure)

1 (120) MD -7.20, 95% CI -13.12 to -1.

28, mean systolic blood pressure

significantly lower in the immer-

sion group

Adverse effects for women (di-

astolic blood pressure)

1 (120) MD -10.20, 95% CI -13.70 to -

6.70, mean diastolic blood pres-

sure significantly lower in the im-

mersion group

Adverse effects for women (ar-

terial blood pressure)

1 (120) MD -10.50, 95% CI -14.68 to

-6.32, mean arterial blood pres-

sure significantly lower in the im-

mersion group

Adverse effects for women (ma-

ternal infection - perineal, sys-

temic, uterine or increase in

temperature)

5 (1295) RR 0.99, 95% CI 0.50 to 1.96,


groups


(postpartum depression - score

of more than 11 on the Ed-

inburgh Postnatal Depression

Scale EPDS)

2 (370) RR 1.38, 95% CI 0.85 to 2.24,


groups in the incidence of post-

partum depression

Adverse effects for infants (pres-

ence of meconium stained

liquor)

5 (1260) RR 0.95, 95% CI 0.76 to 1.19,


ference between groups for meco-

nium staining

Adverse effects for infants (ab-

normal fetal heart rate patterns)

3 (487) RR 0.75, 95% CI 0.34 to 1.67,

(random effects; heterogeneity: I2 = 57%, Tau2 = 0.22, Chi2 test

for heterogeneity P = 0.13), no

evidence of a significant differ-




ence

Adverse effects for infants (um-

bilical artery pH less than 7.20)

1 (110) RR 5.18, 95% CI 0.25 to 105.

51, no evidence of a significant

difference between groups

Adverse effects for infants (tem-

perature greater than 37.8 de-

grees C as an indicator for in-

fection)

1 (274) RR 1.00, 95% CI 0.06 to 15.83,



Adverse effects for infants

(neonatal infection)

5 (1295) RR 2.00, 95% CI 0.50 to 7.94,



Admission to neonatal intensive

care unit

3 (1571) RR 1.06, 95% CI 0.71 to 1.57,




five minutes

5 (1834) RR 1.58, 95% CI 0.63 to 3.93,




term follow-up



4.1. Immersion versus no im-

mersion in the second stage

of labour (3 studies, 286

women)


Pain intensity - number of

women reporting moderate to

severe pain on an ordinal scale

1 (117) RR 1.06, 95% CI 0.73 to 1.53,


groups in women experiencing

moderate to severe pain




perience (reported that they did

not cope satisfactorily with their

pushing efforts)

1 (117) RR 0.24, 95% CI 0.07 to 0.80,


immersion group reported low

satisfaction





perience (satisfaction with

labour and birth on scale of 0-6

where 0 is not at all satisfied)

1 (60) MD 0.03, 95% CI -0.64 to 0.70,


mean satisfaction scores


baby interaction


Breastfeeding 1 (60) RR 0.86, 95% CI 0.69 to 1.08,










ineal trauma - episiotomy)

2 (179) RR 0.75, 95% CI 0.35 to 1.60,




ineal trauma - second-degree

tear)

2 (179) RR 1.21, 95% CI 0.65 to 2.24,




ineal trauma - third or fourth

degree tear)

1 (60) RR 1.54, 95% CI 0.07 to 36.11,



Adverse effects

for women (postpartum haem-

orrhage more than 500 ml)

1 (120) RR 0.14, 95% CI 0.01 to 2.71,




ternal temperature)

1 (60) MD 0.20, 95% CI -0.18 to 0.58,


ference in mean temperature be-

tween groups

Adverse effects for infants (pres-

ence of meconium stained

liquor)

2 (180) RR 1.32, 95% CI 0.63 to 2.80,



Adverse effects for infants (um-

bilical artery pH less than 7.20)

1 (116) RR 0.89, 95% CI 0.45 to 1.75,






Adverse effects for infants (an-

tibiotics given to neonate)

1 (60) RR 1.50, 95% CI 0.17 to 13.52,



Adverse effects for infants (posi-

tive neonatal swab of ear, mouth

or umbilicus)

1 (154) RR 1.89, 95% CI 0.90 to 3.96,





unit

2 (180) RR 0.79, 95% CI 0.25 to 2.49,




five minutes

1 (119) RR 4.92, 95% CI 0.24 to 100.




term follow-up



4.2. Early versus late immer-

sion during the first stage of

labour (1 study, 200 women)






perience



baby interaction



Assisted vaginal birth Outcome not reported

Caesarean section Outcome not reported

Adverse effects for women Outcome not reported





(Neonatal infection)

1 (200) RR 3.00, 95% CI 0.12 to 72.77,





unit

Not estimable


one minute

1 (200) Not estimable


term follow-up





CI: confidence interval; MD: mean difference; RR: risk ratio; VAS: visual analogue scale

Table 17. (5.) Results by individual review - aromatherapy

5. Aromatherapy for pain management in labour, 2 studies, 535 women (Smith 2011c)

5.1. Aromatherapy

versus standard care (1 study,

513 women)


Pain intensity (women asked to

rate their level of pain after re-

ceiving aromatherapy)

1 (513) No data provided for the stan-

dard care group, so data could not

be analysed




perience



baby interaction





Table 17. (5.) Results by individual review - aromatherapy (Continued)



ference



ference

Adverse effects Not reported in any trial



unit

1 (513) RR 0.08, 95% CI 0.00 to 1.42,


ference


five minutes



term follow-up



5.2. Aromatherapy (ginger)

versus aromatherapy (lemon

grass) (1 study, 22 women)


Pain intensity (assessed on a

visual analogue scale before,

during or after the bath and

24 hours post-partum (McGill

Pain Questionnaire)

1 (22) Median values reported and so

data could not be analysed.




perience



baby interaction





ference



Table 17. (5.) Results by individual review - aromatherapy (Continued)



ference



1 (22) No women in either group had a

postpartum haemorrhage



unit

1 (22) No babies in either group were

admitted to NICU


five minutes



term follow-up






Table 18. (6.) Results by individual review - relaxation techniques

6. Relaxation techniques for pain management in labour, 11 studies, 1574 women (Smith 2011b)

6.1. Relaxation (yoga, mu-

sic or audio-analgesia) ver-

sus standard care (11 studies,

1574 women)


Relaxation versus standard care Pain intensity (Latent phase)

(method of pain assessment not

reported)

1 (40 women) MD -1.25, 95% CI -1.97 to -0.

53, a significant reduction in pain

intensity for women receiving in-

struction on relaxation

Pain intensity (Active phase)

(method of pain assessment not

reported)

2 (74 women) MD -2.48, 95% CI -3.13 to -1.

83, a significant reduction in pain

intensity for women receiving in-

struction on relaxation

Pain intensity (memory of pain

at 3 months follow-up assessed

using a Lickert scale from 1 to

7, where 7 is “worst imaginable

pain”)

1 (904) MD 0.00, 95% CI -0.22 to 0.


difference



Table 18. (6.) Results by individual review - relaxation techniques (Continued)

Relaxation versus standard care Satisfaction with pain relief

(postnatal interview 2 hours af-

ter delivery)

1 (40 women) RR 8.00, 95% CI 1.10 to 58.19,

a significant increase in satisfac-

tion for women receiving relax-

ation

Relaxation versus standard care Sense of control in labour Outcome not reported

Relaxation versus standard care Satisfaction with childbirth ex-

perience (Wijma

Delivery Experience Question-

naire 3 months postnatal)

1 (904) MD -0.40, 95% CI -3.47 to 2.


difference (analysis adjusted for

clustering)

Relaxation versus standard care Effect on mother/baby interac-

tion


Relaxation versus standard care Breastfeeding Outcome not reported

Relaxation versus standard care Assisted vaginal birth 2 (86 women) RR 0.07, 95% CI 0.01 to 0.50,

significantly fewer women had

assisted vaginal birth in the relax-

ation group

Assisted vaginal birth 1 (904 women) cluster trial RR 1.15, 95% CI 0.82 to 1.61,


ference

Relaxation versus standard care Caesarean section 3 (990 women) Data from trials not combined in

a meta-analysis (2 parallel trials

and 1 cluster trial) due to consid-

erable heterogeneity

Relaxation versus standard care Averse effects (for women and

infants)


Relaxation versus standard care Admission to special care baby


unit


Relaxation versus standard care Apgar score less than seven at

five minutes

1 (34 women) RR 0.47, 95% CI 0.02 to 10.69,


ference

Relaxation versus standard care Poor infant outcomes at long-

term follow-up


Relaxation versus standard care Cost Outcome not reported




Yoga versus standard care Pain intensity (Latent phase)

(visual analogue sensation of

pain scale VASPS)

1 (66) MD -6.12, 95% CI -11.77 to -

0.47, a significant reduction in

pain intensity for women receiv-

ing yoga

Yoga versus standard care Satisfaction with pain relief

(method of assessment not re-

ported)

1 (66) MD 7.88, 95% CI 1.51 to 14.

25, significantly greater satisfac-

tion for women receiving yoga

Yoga versus standard care Sense of control in labour Outcome not reported

Yoga versus standard care Satisfaction with childbirth ex-

perience (not clear which tool

used for assessment - several

were reported)

1 (66) MD 6.34, 95% CI 0.26 to 12.

42, significantly greater satisfac-

tion for women receiving yoga

Yoga versus standard care Effect on mother/baby interac-

tion


Yoga versus standard care Breastfeeding Outcome not reported

Yoga versus standard care Assisted vaginal birth Outcome not reported

Yoga versus standard care Caesarean section Outcome not reported

Yoga versus standard care Adverse effects (for women and

infants)


Yoga versus standard care Admission to special care baby


unit


Yoga versus standard care Apgar score less than seven at

five minutes

1 (66) No babies in yoga or control

group had an Apgar score less

than seven at five minutes

Yoga versus standard care Poor infant outcomes at long-

term follow-up


Yoga versus standard care Cost Outcome not reported

Music versus standard care Pain intensity (Latent phase)


pain scale VASPS)

1 (60) MD -0.17, 95% CI -1.41 to 1.


difference

Pain intensity (Active phase)


pain scale VASPS)

1 (60) MD -0.18, 95% CI -0.70 to 0.


difference




Music versus standard care Satisfaction with pain relief Outcome not reported

Music versus standard care Sense of control in labour Outcome not reported

Music versus standard care Satisfaction with childbirth ex-

perience


Music versus standard care Effect on mother/baby interac-

tion


Music versus standard care Breastfeeding Outcome not reported

Music versus standard care Assisted vaginal birth Outcome not reported

Music versus standard care Caesarean section 1 (60 women) RR 1.25, 95% CI 0.37 to 4.21,


ference

Music versus standard care Adverse effects (for women and

infants)


Music versus standard care Admission to special care baby


unit


Music versus standard care Apgar score less than seven at

five minutes


Music versus standard care Poor infant outcomes at long-

term follow-up


Music versus standard care Cost Outcome not reported

Audio-analgesia versus standard

care



care

Satisfaction with pain relief

(women’s satisfaction with sea

noise)

1 (24) RR 2.00, 95% CI 0.82 to 4.89,


ference


care



care


perience



care


tion






care



care



care



care

Adverse effects (for women and

infants)



care



unit



care


five minutes



care


term follow-up



care




CI: confidence interval; MD: mean difference; RR: risk ratio

Table 19. (7.) Results by individual review - acupuncture

7. Acupuncture or acupressure for pain management in labour, 13 studies, 2391 women (Smith 2011a)

7.1. Acupuncture or acupres-

sure versus placebo/standard

care/no treatment (12 studies,

1858 women)


Acupuncture versus placebo

control

Pain intensity 2 (240) Standardised mean difference

(SMD) 0.04, 95% confidence in-

terval (CI) -0.22 to 0.30, no evi-

dence of a significant difference


control


significantly more women in the

acupuncture group were more

satisfied with pain relief



Table 19. (7.) Results by individual review - acupuncture (Continued)


control



control


perience



control


baby interaction



control



control



ference


control



ference


control



control



unit



control


five minutes

1 (208) RR 0.32, 95% CI 0.01 to 7.79,


ference


control


term follow-up



control


Acupuncture versus standard

care

Pain intensity 1 (90) SMD -0.14, 95% CI -0.55 to 0.


difference


care



ference


care






care


perience



care


baby interaction



care



care



acupuncture group had assisted

vaginal birth


care



ference


care



care



unit



care


five minutes

3 (706) RR 0.60, 95% CI 0.12 to 2.99,


ference


care


term follow-up



care


Acupuncture versus no treat-

ment

Pain intensity 1 (163) SMD -1.00, 95% CI -1.33 to -0.

67, significantly more women in

the acupuncture group reported

less intense pain


ment



ment



ment


perience






ment


baby interaction



ment



ment



ference


ment



ference


ment



ment



unit



ment


five minutes



ment


term follow-up



ment


Acupressure versus placebo

control

Pain intensity 1 (120) SMD -0.55, 95% CI -0.92 to -

0.19, significantly more women

in the acupressure group reported

less intense pain


control



control



control


perience



control


baby interaction



control






control



control



acupressure group had caesarean

section


control



control





control


five minutes



control


term follow-up



control


Acupressure versus combined

control

Pain intensity 2 (322) SMD -0.42, 95% CI -0.65 to -

0.18, significantly more women

in the acupressure group reported

less intense pain


control



control



control


perience

1 (211) MD 4.80, 95% CI -2.29 to 11.


difference


control


baby interaction



control



control



ference





control



ference


control



control





control


five minutes

1 (120) No infant in either group had an

Apgar score less than seven at five

minutes


control


term follow-up



control


7.2. Acupuncture versus a dif-

ferent type of acupuncture

(no studies)

7.3.Acupuncture versus ster-

ile water injection (1study,

128 women)


Acupuncture versus sterile wa-

ter injection



ter injection

Satisfaction with pain relief 1 (128) MD 18.60, 95% CI 11.54 to 25.


the sterile water group were more

satisfied with pain relief


ter injection



ter injection


perience



ter injection


baby interaction



ter injection






ter injection



ference


ter injection



ference


ter injection



ter injection



unit



ter injection


five minutes



ter injection


term follow-up



ter injection


Combined control = placebo and no treatment



CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference

Table 20. (8.) Results by individual review - massage, reflexology and other manual methods

8. Massage, reflexology and other manual methods for pain management in labour, 6 studies, 401 women (Smith 2012)

8.1. Massage versus standard

care (4 studies, 239 women)


Pain intensity during first stage

of labour

4 (225) SMD -0.82, 95% CI -1.17 to -

0.47, intensity of pain during the

first stage of labour was reduced

in the massage group compared

with usual care

Pain intensity during second

stage of labour

2 (124) SMD -0.98, 95% CI -2.23 to 0.


in pain intensity



Table 20. (8.) Results by individual review - massage, reflexology and other manual methods (Continued)

Pain intensity during third stage

of labour

2 (122) SMD -1.03, 95% CI -2.17 to 0.


in pain intensity

Satisfaction with pain relief 2 (110) Results not combined for 2 stud-

ies due to heterogeneity

Sense of control in labour 1 (40) MD -6.10, 95% CI -13.11 to 0.


in sense of control in labour


perience



tion









Adverse effects for women and

infants




unit

1 (44) RR 1.93, 95% CI 0.13 to 28.79,




five minutes



term follow-up



8.2. One manual method ver-

sus different manual method

(no studies)

8.3. Massage versus music (1

study, 101 women)






women reporting severe pain

1 (101) RR 0.40, 95% CI 0.18 to 0.

89, significantly fewer women in

the massage group reported se-

vere pain compared to the music

group




perience



tion






infants




unit



five minutes



term follow-up



8.3. Massage versus breathing

exercises (1 study, 28 women)






perience






tion






infants




unit



five minutes



term follow-up





CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference

Table 21. (9.) Results by individual review - TENS

9. Transcutaneous electrical nerve stimulation (TENS) for pain management in labour, 17 studies, 1455 women (Dowswell

2009)

9.1. TENS versus placebo

or standard care (17 studies,

1455 women)


TENS (to the back) versus

placebo/usual care



during labour

2 (147) Average RR 0.67, 95% CI 0.32


geneity: I2 = 49%, Tau2 = 0.18,



difference


placebo/usual care

Pain intensity - pain scores 2 (299) Average SMD -1.01, 95% CI -3.

00 to 0.97 (random effects: het-



Table 21. (9.) Results by individual review - TENS (Continued)

erogeneity: I2 = 93%, Tau2 = 1.

92, Chi2 test for heterogeneity P

= 0.0002), no evidence of a sig-

nificant difference

TEN (to the back) versus

placebo/usual care



ference

TENS (to the back) versus usual

care

Sense of control in labour 1 (24) Data not analysed (standard de-

viations inconsistent)

TENS (to the back) versus usual

care


perience

1 (24) Data not analysed (standard de-

viations inconsistent)

TENS (to the back)

versus placebo/usual care


baby interaction


TENS (to the back)




placebo/usual care



ference


placebo/usual care



ference

TENS (to the back) versus con-

trol

Adverse effects for infants (fetal

distress)

1 (200) RR 0.33, 95% CI 0.01 to 8.09,


ference

TENS (to the back)




unit


TENS (to the back)



five minutes


TENS (to the back)



term follow-up


TENS (to the back)



TENS (to acupuncture points)

versus placebo



during labour

2 (290) RR 0.41, 95% CI 0.31 to 0.

54, significantly fewer women in

TENS group reported severe pain




compared with controls


versus control (no pain relief )

Satisfaction with pain relief 1 (90) RR 4.10, 95% CI 1.81 to 9.


TENS group were satisfied with

pain relief compared with con-

trols


versus placebo/control (no

treatment)




treatment)


perience




treatment)


baby interaction




treatment)



versus placebo

Assisted vaginal birth 1 (100) RR 4.50, 95% CI 1.02 to 19.


TENS group had assisted vaginal

births

TENS (Limoge current to cra-

nium) versus placebo



ference


versus placebo



ference

TENS (Limoge current to cra-

nium) versus placebo



ference


versus placebo


distress)

1 (100) RR 1.00, 95% CI 0.06 to 15.55)

, no evidence of a significant dif-

ference



treatment)



unit







treatment)


five minutes




treatment)


term follow-up




treatment)


9.2. TENS versus a different

type of TENS (no studies)

9.3. TENS versus sterile water

injection (1 study, 22 women)


Pain intensity - pain score

measured using visual analogue

scale (VAS) in labour

1 (22) SMD 5.45, 95% CI 3.49 to 7.42,

women in the TENS group more

likely to have a higher mean pain

score than women in the ster-

ile water group, “The study mea-

sured pain on a scale with scores

recorded in millimetres, it was

not clear how the 10 cm scale was

labelled and the reported stan-

dard deviations are much smaller

than would be expected with this

type of scale, therefore results

should be interpreted with cau-

tion”


Sense of control in labour 1 (22) Data not suitable for analysis


perience

1 (22) Data not suitable for analysis


baby interaction







Caesarean section 1 (22) RR 7.62, 95% CI 0.46 to 126.


difference




unit



five minutes



term follow-up





CI: confidence interval; RR: risk ratio; SMD: standardised mean difference

Table 22. (1.) Results by individual review - inhaled analgesia

1. Inhaled analgesia for pain management in labour, 26 studies, 2967 women (Klomp 2012)

1.1. Inhaled analgesia versus

placebo control/no treatment

(9 studies, 1495 women)


Pain intensity during the first

stage of labour (severe/extreme

pain)

2 (310) Average RR 0.06, 95% CI 0.01

to 0.34, (random effects: hetero-

geneity: I2 = 51%, Tau2 = 1.08,

Chi2 test for heterogeneity P =0.

15), significantly fewer women in

the inhaled analgesia group expe-

rienced severe pain

Pain intensity during the first

stage of labour (VAS 0-10 after

one hour)

1 (509) MD -3.50, 95% CI -3.75 to -3.

25, mean pain score was signifi-

cantly lower in the inhaled anal-

gesia group




Table 22. (1.) Results by individual review - inhaled analgesia (Continued)



perience



tion










(vomiting)

2 (619) RR 9.05, 95% CI 1.18 to 69.



rienced vomiting

Adverse effects for women (nau-

sea)

1 (509) RR 43.10, 95% CI 2.63 to 706.



rienced nausea (very wide CI)


(dizziness)

1 (509) RR 113.98, 95% CI 7.09

to 1833.69, significantly more

women in the inhaled analgesia

group experienced dizziness (ex-

tremely wide CI)


(drowsiness)

1 (509) RR 77.59, 95% CI 4.80 to 1254.


the inhaled analgesia group ex-

perienced drowsiness (extremely

wide CI)


(neonatal asphyxia)

1 (110) RR 1.11, 95% CI 0.26 to 4.73,


groups



unit






five minutes

1 (200) RR 9.00, 95% CI 0.49 to 165.00,


groups


term follow-up



1.2.1. Inhaled analgesia ver-

sus a different type of inhaled

analgesia, nitrous oxide ver-

sus flurane (14 studies, 752

women)


Pain intensity - pain score -

VAS 0-100 first stage of labour

- where 100 is most severe pain

3 (123) Average mean difference MD 13.

87, 95% CI 4.02 to 23.72, (ran-

dom effects: heterogeneity: I2 =

64%, Tau2 = 47.26, Chi2 test

for heterogeneity P =0.06), the

mean pain score was significantly

higher in the nitrous oxide group

compared to the flurane group

(flurane better pain relief )

Pain intensity - pain relief score

- VAS 0-100, where 100 is the

most pain relief

2 (140) Average mean difference MD -

16.92, 95% CI -27.64 to -6.20,

(random effects: heterogeneity: I2 = 70%, Tau2 = 42.58.80, Chi2 test for heterogeneity P =0.07)

, the mean pain relief score was

significantly lower in the nitrous

oxide group compared to the flu-

rane group (flurane better pain

relief )


during the first and second

stages of labour (proportion

with considerable or complete

relief )

2 (98) RR 0.97, 95% CI 0.80 to 1.18,


groups





during the second stage of

labour (proportion with good

or excellent pain relief )

4 (323) RR 0.89, 95% CI 0.78 to 1.01,


groups



perience



tion




there were fewer assisted vaginal

births in the nitrous oxide group,

although this difference did not

reach statistical significance

Caesarean section 1 (98) Not estimable - no CS in either

group

Adverse effects for women (am-

nesia)

4 (281) Average RR 0.26, 95% CI 0.03

to 2.38, (random effects: hetero-

geneity: I2 = 74%, Tau2 = 2.76,

Chi2 test for heterogeneity P =

0.02), there was less amnesia re-

ported in the nitrous oxide group,




(drowsiness)

1 (80) Not estimable - no drowsiness in

either group


(drowsiness), VAS 0-100 mm

2 (57) MD -12.97, 95% CI -22.33 to

-3.62, significantly lower mean

drowsiness score with nitrous ox-

ide compared to flurane group,

(nitrous oxide better)


(dizziness)

2 (204) RR 0.80, 95% CI 0.40 to 1.61,







sea)

6 (378) RR 3.30, 95% CI 1.64 to 6.63,


nitrous oxide group experienced

nausea compared to the flurane

group


(vomiting)

4 (261) RR 2.66, 95% CI 1.06 to 6.70,


nitrous oxide group experienced

vomiting compared to the flurane

group


(blood loss)

2 (185) MD 6.00, 95% CI -32.91 to 44.

91, no significant difference be-

tween groups in blood loss

Adverse effects for infants (neu-

rologic and adaptive capacity

score NACS <35 at 2 hours af-

ter delivery)

3 (170) RR 1.45, 95% CI 0.91 to 2.33,

more babies in the nitrous oxide

group had a NACS score of <35,







five minutes

6 (409) RR 0.22, 95% CI 0.01 to 4.47,


groups (N.B. 5 of trials had no

babies with Apgar score less than

seven at five minutes)


term follow-up



1.2.2. Inhaled analgesia of

one strength versus a differ-

ent strength (2 studies, 625

women)




during the first stage of labour

(good to complete pain relief )

1 (501) RR 1.05, 95% CI 0.94 to 1.


tween 50% and 70% nitrous ox-

ide groups






labour (good to complete relief )

1 (501) RR 0.97, 95% CI 0.87 to 1.



ide groups



perience



tion




14, fewer assisted vaginal births

in the 50% nitrous oxide group,



Caesarean section 1 (501) RR 0.31, 95% CI 0.06 to 1.

53, fewer caesarean sections in

the 50% nitrous oxide group, al-

though this difference did not



(vomiting)

1 (501) RR 1.29, 95% CI 0.86 to 1.94,

less vomiting reported in the 70%

nitrous oxide group, although

this difference did not reach sta-

tistical significance



1 (501) RR 0.80, 95% CI 0.38 to 1.70,

fewer women experienced post-

partum haemorrhage in the 50%

nitrous oxide group, although

this difference did not reach sta-

tistical significance

Adverse effects for women (hy-

poxaemia)

1 (501) RR 1.00, 95% CI 0.07 to 14.



ide groups

Adverse effects for infants Outcome not reported






unit



five minutes



term follow-up



1.2.3. Inhaled analgesia using

one type of delivery system

versus a different system (2

studies, 75 women)



Nitrous oxide alone versus ni-

trous oxide with nasal supple-

ment


during the first stage of labour

(considerable to complete pain

relief )

1 (42) RR 1.18, 95% CI 0.94 to 1.48,


groups



perience



tion




Methoxyflurane us-

ing Penthrane Analgizer versus

methoxyflurane using Cyprane

inhaler



groups

Nitrous oxide alone versus ni-

trous oxide with nasal supple-

ment


(vomiting)

1 (49) RR 1.76, 95% CI 0.77 to 4.

00, more vomiting reported in

the nitrous oxide alone group,






Methoxyflurane us-

ing Penthrane Analgizer versus

methoxyflurane using Cyprane

inhaler


(vomiting)

1 (26) Not estimable - no incidence of

vomiting in either group

Analgizer versus methoxyflu-

rane using Cyprane inhaler



1 (26) RR 0.29, 95% CI 0.01 to 6.50,


groups

Analgizer versus methoxyflu-

rane using Cyprane inhaler


(mild pre-eclampsia)

1 (26) RR 0.86, 95% CI 0.06 to 12.28,


groups




unit



five minutes

Outcome not in a suitable format

(only reported mean and SD)


term follow-up



1.3. Inhaled analgesia versus

TENS (1 study, 20 women)


Pain intensity during first stage

of labour (moderate to severe)

1 (19) RR 1.10, 95% CI 0.84 to 1.45,








perience



baby interaction









infants




unit



five minutes

Outcome not reported in this for-

mat


term follow-up




Table 23. (2.) Results by individual review - parenteral opioids versus placebo/IM opioids versus different IM opioids

2. Parenteral opioids for maternal pain management in labour, 57 studies (Ullman 2010)

2.1. Parenteral opioids versus

placebo or no treatment (3

studies 226 women)


IM pethidine versus placebo Maternal pain relief 30 minutes

after drug administration, de-

fined as a reduction in visual

analogue scale (VAS) score of at

least 40 mm

1 (50) RR 25.00, 95% CI 1.56 to 400.


the pethidine group had a greater

reduction in pain score, CI very

wide

IM pethidine versus placebo Maternal satisfaction 30 min-

utes after administration of

study drug

1 (50) RR 7.00, 95% CI 0.38 to 128.


difference



perience



tion





(Continued)


IM pethidine versus placebo Assisted vaginal birth 1 (50) RR 0.86, 95% CI 0.34 to 2.19,


ference

IM pethidine versus placebo Caesarean section 1 (50) RR 0.83, 95% CI 0.29 to 2.38,


ference

IM pethidine versus placebo Adverse effects for women -

Nausea and vomiting

2 (166) RR 1.47, 95% CI 0.65 to 3.31,


ference

IM pethidine versus placebo Adverse effects for infants -

Neonatal resuscitation

1 (50) RR 1.67, 95% CI 0.45 to 6.24,


ference

IM pethidine versus placebo Admission to special care baby


unit

1 (50) RR 1.00, 95% CI 0.07 to 15.12,


ference


five minutes


Poor infant outcomes at follow-

up



2.2.1. IM opioids versus dif-

ferent IM opioids (15 differ-

ent comparisons, 36 studies)

Pain intensity No. of studies (no. women) Results

IM meptazinol versus IM pethi-

dine

Assessment of analgesic effect

measured at 3 to 5 days post-

partum (not defined how mea-

sured)

1 (801) RR 1.01, 95% CI 0.91 to 1.12,


ference

Pain intensity one hour after

drug administration - rated as

severe on five-point scale

2 (239) average RR 1.11, 95% CI 0.69


geneity: I2 = 43%, Tau2 = 0.08,



difference




(Continued)

PCA (IM) meptazinol versus

PCA (IM) pethidine

Pain scores measured one day

postpartum

1 (10) MD -17.60, 95% CI -49.93 to


cant difference

IM diamorphine + prochlor-

perazine versus IM pethidine +

prochlorperazine

Global assessment of pain relief

evaluated at 24 hours - rated as

‘fair’ or ‘poor’ pain relief

1 (133) RR 0.88, 95% CI 0.67 to 1.16,


ference

Pain intensity rated as moder-

ate or severe one hour after drug

administration

1 (133) RR 0.85, 95% CI 0.72 to 1.01,


ference

IM tramadol versus IM pethi-

dine

Pain intensity (defined in dis-

parate ways in studies) - rated as

‘poor’ pain relief

4 (243) RR 1.56, 95% CI 1.10 to 2.21,

significantly more women had

poor pain relief with tramadol

compared with pethidine

IM dihydrocodeine versus IM

pethidine

Pain intensity rate as ‘poor’ pain

relief one hour after drug ad-

ministration

1 (138) RR 1.09, 95% CI 0.64 to 1.86,


ference

IM pentazocine versus pethi-

dine

Pain intensity rated as ‘good’ or

‘very good’ pain relief at birth

2 (253) RR 1.08, 95% CI 0.92 to 1.27,


ference

IM nalbuphine versus pethi-

dine

Number of women reported as

being ‘free of pain’

1 (40) RR 6.00, 95% CI 0.79 to 45.42,


ference

Pain intensity at 30 minutes,

rated as severe

1 (295) RR 0.86, 95% CI 0.59 to 1.26,


ference

Pain intensity at 60 minutes

(VAS), at peak of contraction

1 (72) MD -8.00, 95% CI -18.55 to 2.


difference

IM morphine versus pethidine Number of women rating their

pain relief as ‘poor’

1 (90) RR 1.22, 95% CI 0.56 to 2.66,


ference

IM pentazocine versus IM

pethilorfan

Number of women reporting

‘no pain relief ’ at one hour

1 (69) RR 1.22, 95% CI 0.77 to 1.95,


ference




Satisfaction with pain relief No. of studies (no. women) Results




(Continued)

PCA (IM) meptazinol versus

PCA (IM) pethidine

Satisfied with mode of admin-

istration

1 (10) RR 1.00, 95% CI 0.71 to 1.41,


ference


dine

Pain relief reported as “poor” or

“partial relief ”

3 (365) RR 1.23, 95% CI 0.74 to 2.05,


ference


dine

Maternal satisfaction with anal-

gesia at 24 hours; numbers dis-

satisfied

1 (72) RR 0.73, 95% CI 0.55 to 0.96,


nalbuphine group were dissatis-

fied with pain relief




Satisfation with childbirth ex-

perience









Effect on mother/baby inter-

action









Assisted vaginal birth No. of studies (no. women) Results


dine



ference

Diamor-

phine + prochloprerazine versus

pethidine + prochloprerazine



ference

IM tramadol versus pethidine Assisted vaginal birth 3 (260) RR 0.56. 95% CI 0.12 to 2.56,


ference


dine



ference




(Continued)


dine



ference


pethilorfan



ference




Caesarean section No. of studies (no. women) Results

IM pethidine versus placebo Caesarean section 1 (50) RR 0.83, 95% CI 0.29 to 2.38,


ference


dine

Caesarean section 3 (1266) average RR 0.56, 95% CI 0.16

to 2.00, (random effects; hetero-

geneity: I2 = 75%, Tau2 = 0.84,



difference

Diamor-

phine + prochloprerazine versus

pethidine + prochloprerazine



ference


dine



ference

IM nalbuphine versus IM

pethidine



ference

IM Avacan versus IM penta-

zocine



ference




Adverse effects for women No. of studies (no. women) Results

IM meptazinol versus pethidine Nausea 3 (1590) RR 1.11, 95% CI 0.95 to 1.28,


ference




(Continued)

IM meptazinol versus pethidine Vomiting 3 (1589) RR 1.25, 95% CI 1.06 to 1.

47, significantly more women re-

ported vomiting with meptazinol

compared with pethidine

IM meptazinol versus pethidine Maternal sleepiness 3 (1590) average RR 0.55, 95% CI 0.28

to 1.07, (random effects; het-

erogeneity: I2 = 44%, Tau2 =

0.18, Chi2 test for heterogene-

ity P = 0.17), fewer women re-

ported sleepiness in the meptazi-

nol group, although the differ-

ence did not reach statistical sig-

nificance

PCA IM meptazinol versus

PCA IM pethidine

Nausea score in labour (rated 1

day after delivery)

1 (10) MD -8.00, 95% CI -48.70 to 32.


difference


PCA IM pethidine

Drowsiness score in labour

(rated 1 day after delivery)

1 (10) MD 5.60, 95% CI -28.19 to 39.


difference



prochlorperazine

Vomiting 1 (133) RR 0.39, 95% CI 0.17 to 0.

86, number of women vomiting

significantly lower with diamor-

phine compared with pethidine



prochlorperazine

Maternal sleepiness (one hour

after study drug administra-

tion)

1 (133) RR 0.93, 95% CI 0.52 to 1.66,


ference

IM tramadol versus pethidine Nausea and vomiting 6 (454) Average RR 0.97, 95% CI 0.34


geneity: I2 = 72%, Tau2 = 1.09,



difference

IM tramadol versus pethidine Maternal sleepiness 5 (409) RR 0.57, 95% CI 0.33 to 0.97,


for heterogeneity P = 0.007), sig-

nificantly fewer women in the

tramadol group reported sleepi-

ness




(Continued)

IM tramadol + triflupromazine

versus pethidine + triflupro-

mazine

Nausea 1 (40) RR 0.82, 95% CI 0.13 to 5.25,


ference



mazine

Vomiting 1 (40) RR 0.40, 95% CI 0.02 to 9.35,


ference



mazine

Maternal sleepiness 1 (40) RR 2.86, 95% CI 0.68 to 12.12,

sleepiness was more frequently

reported by women who re-

ceived tramadol, though no sta-

tistically significant difference be-

tween groups was detected


pethidine

Nausea and vomiting 1 (138) RR 0.87, 95% CI 0.40 to 1.88,


ference


pethidine



ference


pethidine

Nausea 3 (391) RR 0.46, 95% CI 0.24 to 0.90,

fewer women in the pentazocine

group reported nausea compared

to the pethidine group


pethidine

Vomiting 1 (73) RR 0.92, 95% CI 0.27 to 3.14,


ference


pethidine



ference


pethidine

Nausea 1 (301) RR 0.62, 95% CI 0.42 to 0.91,

fewer women in the nalbuphine

group reported nausea compared

to the pethidine group


pethidine

Vomiting 1 (301) RR 0.41, 95% CI 0.22 to 0.76,


group reported vomiting com-

pared to the pethidine group


pethidine



group reported both nausea and




(Continued)

vomiting compared to the pethi-

dine group


pethidine

Sleepiness 1 (72) RR 3.78, 95% CI 0.86 to 16.60,


ference

IM phenazocine versus IM

pethidine

Vomiting 1 (212) RR 0.39, 95% CI 0.20 to 0.78,

fewer women in the phenazocine

group reported vomiting com-

pared to the pethidine group

IM morphine versus IM pethi-

dine



ference

IM morphine versus IM pethi-

dine



ference

IM butorphanol versus IM

pethidine

Nausea 1 (80) RR 0.20, 95% CI 0.01 to 4.04,


ference


pethidine

Vomiting 1 (80) RR 0.50, 95% CI 0.05 to 5.30,


ference

IM tramadol versus no treat-

ment

Mean blood loss at delivery (ml) 1 (60) MD 25.70, 95% CI -9.83 to 61.


difference




Adverse effects for infants No. of studies (no. women) Results

IM meptazinol versus pethidine Fetal heart rate changes (decel-

erations)

1 (34) RR 1.23, 95% CI 0.92 to 1.64,


ference

IM meptazinol versus pethidine Naloxone administration 1 (998) RR 0.89, 95% CI 0.77 to 1.02,


ference

IM meptazinol versus pethidine Neonatal resuscitation 2 (1356) RR 1.00, 95% CI 0.95 to 1.05,


ference




(Continued)


PCA IM pethidine

Naloxone administration 1 (10) RR 1.00, 95% CI 0.08 to 11.93,


ference

IM diamorphine + prochlorpre-

razine versus IM pethidine +

prochlorprerazine

Neonatal resuscitation 1 (133) RR 1.21, 95% CI 0.73 to 2.02,


ference

IM tramadol versus pethidine Neonatal respiratory distress 1 (59) RR 2.26, 95% CI 0.64 to 7.89,


ference

IM pentazocine + promazine

versus IM pethidine + pro-

mazine



ference


pethidine

Naloxone administration 1 (72) RR 6.63, 95% CI 0.35 to 123.


difference


pethidine

Neonatal neuro-behavioural 2-

4 hours postnatal

1 (72) MD -3.70, 95% CI -6.14 to

-1.26, babies of women who

received nalbuphine had lower

scores than babies born to women

in the pethidine group


pethidine

Neonatal resuscitation 1 (80) RR 0.33, 95% CI 0.01 to 7.95,


ference


pethidine



ference




Admission to special care

baby unit

No. of studies (no. women) Results

IM meptazinol versus pethidine 1 (199) RR 0.88, 95% CI 0.48 to 1.63,


ference



prochlorprerazine

1 (133) RR 0.58, 95% CI 0.21 to 1.64,


ference


dine

1 (59) RR 2.26, 95% CI 0.64 to 7.89,


ference




(Continued)


pethidine

1 (299) RR 1.07, 95% CI 0.61 to 1.89,


ference





five minutes



dine

3 (616) RR 0.49, 95% CI 0.05 to 5.37,


ference



prochlorprerazine

1 (133) RR 0.35, 95% CI 0.04 to 3.27,


ference


pethidine

1 (62) RR 0.23, 95% CI 0.01 to 4.54,


ference


pethidine

1 (72) RR 0.47, 95% CI 0.04 to 4.99,


ference




Poor infant outcomes at fol-

low-up








CI: confidence interval; IML intramuscular; MD: mean difference; RR: risk ratio

Table 24. (2.) Results by individual review - parenteral opioids - IV opioids versus different IV opioids/parenteral opioids

versus different intervention

Parenteral opioids for maternal pain management in labour, 57 studies (Ullman 2010)

2.2.2. IV opioids versus dif-

ferent IV opioids (12 compar-

isons, 17 studies)





versus different intervention (Continued)

IV fentanyl versus IV pethidine Mean pain score one hour after

drug administration

1 (105) MD -0.20, 95% CI -0.34 to -0.

06, the mean pain score in the IV

fentanyl group was significantly

lower than the mean pain score

in the IV pethidine group

IV butorphanol versus IV

pethidine

Women’s reported mean pain

relief score (not defined)

1 (80) MD 0.67, 95% CI 0.25 to 1.09,

the mean pain relief score was sig-

nificantly higher for the IV bu-

torphanol group compared to the

IV pethidine group


pethidine

Pain score one hour after drug

administration (10-point scale)

1 (80) MD -0.60, 95% CI -1.02 to -0.

18, the mean pain score in the

IV butorphanol group was signif-

icantly lower than the mean pain

score in the IV pethidine group

PCA pentazocine versus PCA

pethidine

Self-reported pain score during

labour

1 (23) SMD -0.76, 95% CI -1.62 to 0.


difference

PCA remifentanil versus PCA

pethidine

Mean pain scores at one hour

after drug administration (a vi-

sual analogue scale (VAS) rang-

ing from 0 (“no pain”) to 10 cm

(“worst imaginable pain”)

2 (122) average MD -8.59, 95% CI -27.

61 to 10.44 (random effects; het-

erogeneity: I2 = 62%, T2 = 136.


= 0.10), no evidence of a signifi-

cant difference

PCA nalbuphine versus PCA

pethidine

Pain score recorded in labour 1 (60) SMD -0.51, 95% CI -1.02 to 0.


difference

PCA fentanyl versus PCA alf-

tentanil

Mean pain scores at 4-6 cm cer-

vical dilatation

1 (21) MD -12.80, 95% CI -32.12 to


difference

PCA fentanyl versus PCA

pethidine

Mean pain scores at one hour

after drug administration (a vi-

sual analogue scale (VAS) rang-

ing from 0 (“no pain”) to 10 cm

(“worst imaginable pain”)

1 (107) MD -0.65, 95% CI -1.56 to 0.


difference



isons, 17 studies)






IV phenazocine versus IV pethi-

dine


(women with fair or poor relief )

1 (194) RR 0.72, 95% CI 0.48 to 1.10,


ference

IV morphine versus IV pethi-

dine

Women satisfied with analgesia

3 days postpartum

1 (141) RR 0.87, 95% CI 0.78 to 0.98,


IV morphine group were satisfied

with pain relief


pethidine

Measured in the postnatal pe-

riod (rated good or excellent)

1 (60) RR 1.29, 95% CI 0.88 to 1.89,


ference


tentanil

Satisfaction with pain relief as

“adequate” or “good” within 6

hours of giving birth

1 (23) RR 1.56, 95% CI 0.93 to 2.60,


ference



isons, 17 studies)




isons, 17 studies)

Satisfaction with childbirth

experience



pethidine


perience

1 (68) MD 1.10, 95% CI 0.46 to 1.74,


ference



isons, 17 studies)


action




isons, 17 studies)

Breastfeeding No. of studies (no. women) Results


pethidine

Breastfeeding at discharge 1 (23) RR 1.00, 95% CI 0.85 to 1.17,





isons, 17 studies)



pethidine



ference






pethidine



ference


pethidine



ference



isons, 17 studies)

Caesarean Section No. of studies (no. women) Results

IV fentanyl versus IV pethidine Caesarean section 1 (105) RR 1.14, 95% CI 0.24 to 5.40,


ference

IV nalbuphine versus IV pethi-

dine



ference


pethidine



ference

IV fentanyl versus IV butor-

phanol



ference


pethidine



ference


pethidine



ference


tentanil



ference


pethidine



ference



isons, 17 studies)






IV fentanyl versus IV pethidine Nausea and/or vomiting 1 (105) RR 0.51, 95% CI 0.17 to 1.55,


ference

IV fentanyl versus IV pethidine Maternal sedation 1 (105) RR 0.05, 95% CI 0.00 to 0.

82, maternal sedation was signif-

icantly lower in women allocated

to the IV fentanyl group

IV phenazocine versus IV pethi-

dine



ference


pethidine

Nausea and/or vomiting 1 (200) RR 0.04, 95% CI 0.00 to 0.67,

fewer women in the butorphanol

group experienced nausea/and or

vomiting compared to the pethi-

dine group


dine

Nausea 1 (20) RR 0.17, 95% CI 0.02 to 1.14,


ference


dine

Vomiting 1 (20) RR 0.25, 95% CI 0.03 to 1.86,


ference

IV nisentil versus IV pethidine Nausea 1 (395) RR 0.71, 95% CI 0.33 to 1.52,


ference

IV nisentil versus IV pethidine Vomiting 1 (395) RR 0.38, 95% CI 0.22 to 0.

66, fewer women in the nisen-

til group experienced vomiting

compared to the pethidine group


pethidine



ference


pethidine

Maternal sleepiness (assessed

using an observer sedation

score: 1 = awake; 2 = sleepy; 3

= eyes closed, but rousable; 4

= eyes closed but rousable by

physical stimuli; 5 = unrous-

able)

1 (105) MD 0.40, 95% CI 0.14 to 0.66,








pethidine



ference


pethidine



ference


tentanil

Nausea 1 (23) RR 2.73, 95% CI 0.66 to 11.30,


ference


pethidine

Maternal sleepiness 1 (107) MD -0.06, 95% CI -0.25 to 0.


difference


pethidine



ference



isons, 17 studies)


IV fentanyl versus IV pethidine Naloxone administration 1 (105) RR 0.16, 95% CI 0.02 to 1.28,


ference

IV fentanyl versus IV pethidine Babies requiring resuscitation/

ventilatory support

1 (105) RR 1.03, 95% CI 0.46 to 2.32,


ference

IV fentanyl versus IV pethidine Neurobehavioural score (1-2

hours after delivery)

1 (105) MD 1.30, 95% CI 0.15 to 2.45,


ference

IV fentanyl versus IV pethidine Neurobehavioural score (2-24


1 (105) MD 0.90, 95% CI -0.42 to 2.


difference


phanol

Babies requiring ventilatory

support

1 (100) RR 11.00, 95% CI 0.62 to 193.


difference


phanol

Naloxone required 1 (100) RR 1.75, 95% CI 0.81 to 3.80,


ference






phanol

Neurobehavioural score (2-4


1 (100) MD 0.00, 95% CI -1.61 to 1.


difference


phanol

Neurobehavioural score (24-36


1 (100) MD -0.50, 95% CI -1.62 to 0.


difference


pethidine



ference


pethidine

Neurobehavioural score (15

minutes post delivery)

1 (56) MD 0.20, 95% CI -0.93 to 1.


difference


pethidine



1 (59) MD 0.60, 95% CI -0.66 to 1.


difference


tentanil

Naloxone required 1 (24) RR 2.36, 95% CI 0.53 to 10.55,


ference


pethidine


minutes post delivery)

1 (63) MD -0.90, 95% CI -2.31 to 0.


difference


pethidine


hours post delivery)

1 (64) MD -0.50, 95% CI -1.95 to 0.


difference



isons, 17 studies)


baby unit/neonatal intensive

care unit



pethidine

1 (17) RR 0.30, 95% CI 0.01 to 6.47,


ference



isons, 17 studies)


five minutes


IV fentanyl versus IV pethidine 1 (105) RR 0.38, 95% CI 0.02 to 9.12,


ference






pethidine

2 (230) RR 1.00, 95% CI 0.06 to 15.77,


ference


phanol

1 (100) RR 1.20, 95% CI 0.39 to 3.68,


ference


pethidine

1 (17) RR 0.13, 95% CI 0.01 to 2.16,


ference


pethidine

1 (41) RR 0.42, 95% CI 0.02 to 9.76,


ference



isons, 17 studies)


low-up




isons, 17 studies)


2.3. Parenteral opioids ver-

sus different interventions (3



Opioids (IM pethidine; IM tra-

madol) versus TENS

Pain relief reported as com-

plete, excellent or moderate at

30 minutes after analgesia (1

study), time point not reported

in the other study

2 (290) average RR 1.15, 95% CI 0.81


geneity: I2 = 64%, T2 = 0.04, Chi2 test for heterogeneity P = 0.10)

, no evidence of a significant dif-

ference





Opioids (IV pethidine; IM

pethidine) versus TENS

Maternal satisfaction with anal-

gesia measured post delivery

(rated as good)

2 (104) RR 1.23, 95% CI 0.79 to 1.92,


ference












Satisfaction with childbirth

experience






action










Opioids (IM tramadol) versus

TENS



difference




Caesarean section No. of studies (no. women) Results


TENS

Caesarean section 1 (200) Not estimable - no caesarean sec-

tions reported in either the opi-

oid or TENS group






madol) versus TENS

Drowsiness 2 (290) RR 8.96, 95% CI 1.13 to 71.07,

women in the opioid group were

more likely to report drowsiness

compared to those in the TENS

group


madol) versus TENS

Nausea and vomiting 2 (290) RR 14.06, 95% CI 1.96 to 100.

61, women in the opioid group

were more likely to report nausea

and vomiting compared to those

in the TENS group










TENS

Fetal distress 1 (200) RR 5.00, 95% CI 0.24 to 102.


difference





baby unit






five minutes






low-up








CI: confidence interval; IV: intravenous; MD: mean difference; RR: risk ratio; SMD: standardised mean difference

Table 25. (3.) Results by individual review - non-opioid drugs

3. Non-opioid drugs for pain management in labour, 18 studies, 2733 women (Othman 2012)

3.1. Non-opioid drugs versus

placebo or no treatment (14



Sedatives Pain intensity - 10 cm VAS at

one hour

1 (50) MD -22.00, 95% CI -35.86 to

-8.14, pain scores significantly

lower in the non-opioid group

Anti-spasmodics Pain intensity - women report-

ing severe pain during first stage

of labour

1 (84) RR 0.88, 95% CI 0.72 to 1.08,


ference

Sedatives Satisfaction with pain relief 2 (204) RR 1.59, 95% CI 1.15 to 2.

21, women in the non-opioid

group were more likely to ex-

press satisfaction with pain re-

lief



Table 25. (3.) Results by individual review - non-opioid drugs (Continued)

Anti-histamines Satisfaction with pain relief 1 (223) RR 1.80, 95% CI 1.16 to 2.

79, 1 trial, women in the non-

opioid group were more likely

to express satisfaction with pain

relief

Sense of control Outcome not reported

Sedatives Satisfaction with childbirth ex-

perience

1 (40) RR 2.16, 95% CI 1.34 to 3.


group were more likely to ex-

press satisfaction with the child-

birth experience


baby interaction


Sedatives Breastfeeding (no definition of

what was meant by breastfeed-

ing provided in the study)

1 (198) RR 0.65, 95% CI 0.36 to 1.17,


ference

Anti-spasmodics Assisted vaginal birth 1 (84) RR 0.45, 95% CI 0.09 to 2.35,


ference

Sedatives Assisted vaginal birth 3 (417) RR 0.93, 95% CI 0.84 to 1.03,


ference

Anti-histamines Assisted vaginal birth 1 (49) RR 3.12, 95% CI 0.13 to 73.


difference

Sedatives Caesarean section 2 (203) RR 3.62, 95% CI 0.40 to 32.


difference

Anti-spasmodics Adverse effects for women (Re-

ported adverse effects included

nausea, vomiting, drowsiness,

tachycardia, headache, blurred

vision, dryness of the mouth,

difficulty in micturition, weak-

ness of the legs, hypotension

and atonic postpartum haemor-

rhage)

1 (84) RR 7.27, 95% CI 0.95 to 55.


difference




Sedatives Adverse effects for women (Re-

ported adverse effects included

nausea, vomiting, drowsiness,

tachycardia, headache, blurred

vision, dryness of the mouth,

difficulty in micturition, weak-

ness of the legs, hypotension

and atonic postpartum haemor-

rhage)

3 (216) RR 1.26, 95% CI 0.67 to 2.35,


ference

Sedatives Adverse effects for infants 2 (387) RR 0.85, 95% CI 0.46 to 1.54,


ference

Anti-histamines Adverse effects for infants Outcome not reported



unit


Sedative-analgesics Apgar score less than seven at

five minutes

3 (259) RR 1.16, 95% CI 0.55 to 2.45,


ference


term follow-up




different type of non-opioid

drug (2 studies, 562 women)



Sedatives versus anti-histamines Satisfaction with pain relief 1 (157) RR 1.52, 95% CI 1.06 to 2.

17, women in the sedative-anal-

gesic group more likely to ex-

press satisfaction with pain re-

lief

Anti-histamine versus different

anti-histamine

Satisfaction with pain relief 1 (289) RR 1.21, 95% CI 1.02 to

1.43, women in the hydrox-

yzine + meperidine group were

more likely to express satisfac-

tion with pain relief when com-

pared to the promethazine +

meperidine group






perience



baby interaction




anti-histamine



ference



Sedatives versus anti-histamines Adverse effects for infants 1 (157) RR 0.89, 95% CI 0.06, 14.00,


ference





anti-histamine


five minutes

1 (289) RR 1.85, 95% CI 0.17 to 20.


difference


term follow-up



3.2. Non-opioid drug versus

same non-opioid drug of a

different dose (1 study, 28

women)



Sedatives Satisfaction with pain relief 1 (19) RR 0.22, 95% CI 0.04 to 1.33,


ference






perience



baby interaction




Sedatives Caesarean section 1 (19) RR 6.00, 95% CI 0.28 to 129.


difference

Sedatives Adverse effects for women (hy-

potension,

blood loss, headache, nausea,

vomiting, difficulty in micturi-

tion and weakness of the legs)

1 (19) RR 0.72, 95% CI 0.09 to 5.59,


ference




unit



five minutes



term follow-up




a different intervention (opi-

oids) (3 studies, 563 women)



Non-steroidal anti-inflamma-

tory drugs (NSAIDs)

Satisfaction with pain relief 1 (76); 1 (77) (same trial, dif-

ferent dose of opioids - 3 arm

trial)

RR 0.50, 95% CI 0.27 to 0.

94; RR 0.44, 95% CI 0.24 to

0.81, women in the non-opioid

group less likely to express sat-

isfaction with pain relief when

compared to the opioid group,

irrespective of dose of opioids




Anti-histamines Satisfaction with pain relief 1 (223) RR 0.73, 95% CI 0.54 to 0.


group less likely to express sat-

isfaction with pain relief when

compared to the opioid group



perience



baby interaction



Anti-histamines Assisted vaginal birth 1 (48) RR 1.00, 95% CI 0.07 to 15.


difference


NSAIDs Adverse effects for women (nau-

sea and vomiting)

1 (76); 1 (77) (same trial, dif-

ferent dose of opioids - 3 arm

trial)

RR 0.64, 95% CI 0.33 to 1.26;

RR 0.54 95% CI 0.29 to 1.03,


ference, irrespective of dose of

opioids




unit



five minutes



term follow-up








Table 26. (4.) Results by individual review - local anaesthetic nerve block

4. Local anaesthetic nerve block for pain management in labour, 12 studies, 1549 women (Novikova 2012)

4.1. Local anaesthetic nerve

block versus placebo (1 study,

200 women)



PCB with 2% lidocaine versus

PCB with distilled water

Satisfaction with pain relief (de-

gree of pain relief rated as excel-

lent/complete)

1 (198) RR 32.31, 95% CI 10.60 to 98.

54, more women in the lidocaine

group were satisfied with pain re-

lief



perience



tion






infants (mother - giddiness,

sweating, tingling of lower

limbs; baby- bradycardia)

1 (200) RR 29.00, 95% CI 1.75 to 479.

61, significantly more side-effects

in mothers and babies in the li-

docaine group



unit



five minutes



term follow-up




block versus opioids (2 stud-

ies, 129 women)




Table 26. (4.) Results by individual review - local anaesthetic nerve block (Continued)


PCB versus intramuscular

pethidine


(pain relief during 1st hour af-

ter administration of analgesia

“complete” or “acceptable”

1 (109) RR 2.52, 95% CI 1.65 to 3.83,

more women in the PCB group

were satisfied with pain relief



perience



tion




pethidine or patient controlled

analgesia with fentanyl











(vomiting)





unit






five minutes

2 (122) Not estimable - None of the ba-

bies had Apgar score less than

seven at five minutes


term follow-up




block versus non-opioid (1

study, 100 women)







promethazine

Satisfaction with pain relief (ex-

cellent or complete relief )

1 (100) RR 1.11, 95% CI 0.67 to 1.84,





perience



tion





promethazine








unit



promethazine


five minutes

1 (100) Not estimable - None of the ba-

bies had Apgar score less than

seven at five minutes


term follow-up




block versus different dose/

agent or timing of anaesthetic

nerve block (8 studies, 1120

women)






PCB 1% lidocaine versus 2%

chloroprocaine

Satisfaction with pain relief -

(proportion with unsatisfactory

pain relief )

1 (60) RR 2.81, 95% CI 0.31 to 25.48,



PCB 0.25% bupivacaine versus

2% chloroprocaine or 1% car-

bacaine



labour (proportion with good

or excellent pain relief )

2 (332) RR 0.93, 95% CI 0.85 to 1.00,





perience



tion




chloroprocaine





chloroprocaine





1% carbacaine


(slight dizziness after injection)

1 (285) RR 0.30, 95% CI 0.03 to 2.89,








2% chloroprocaine


five minutes

1 (47) RR 0.32, 95% CI 0.01 to 7.48,




term follow-up






Table 27. (5.) Results by individual review - epidural

5. Epidural versus non-epidural or no analgesia in labour, 38 studies, 9658 women (Anim-Somuah 2011)

5.1. Epidural versus non-

epidural/no analgesia


Pain intensity (during whole of

labour), using visual analogue

score (VAS) 0 to 10, where 0

represents no pain and 10 worst

pain

3 (1166 women) Average mean difference (MD)

-3.36, 95% CI -5.41 to -1.31

(random effects: heterogeneity:

I2 = 98%, Tau2 = 3.14, Chi2 test

for heterogeneity P <0.00001),

a significant reduction in pain

intensity for women receiving

epidural

Pain intensity (in the first stage

of labour) VAS


-16.35, 95% CI -25.11 to -7.

58 (random effects: heterogene-

ity: I2 = 87%, Tau2 = 65.03,

Chi2 test for heterogeneity P <0.

0001), a significant reduction in

pain intensity for women receiv-

ing epidural

Pain intensity (in the second

stage of labour) VAS


-25.29, 95% CI -40.48 to -10.

11 (random effects: heterogene-

ity: I2 = 96%, Tau2 = 162.74,


00001), a significant reduction

in pain intensity for women re-

ceiving epidural

Maternal satisfaction with pain

relief - dichotomous data: the

proportion of women rating

their satisfaction with analgesia

as excellent, very good, good af-

ter delivery in each group

7 (2929 women) Average RR 1.31, 95% CI 0.84

to 2.05 (random effects: hetero-

geneity: I2 = 100%, Tau2 = 0.

36, Chi2 test for heterogeneity

P <0.00001), no evidence of a

significant difference

Maternal satisfaction with pain

relief - continuous data

2 (272 women) Average standardised mean dif-

ference (SMD) 0.10, 95% CI

-0.49 to 0.70 (random effects:

heterogeneity: I2 = 62%, Tau2 =

0.12, Chi2 test for heterogene-

ity P = 0.10), no evidence of a

significant difference



Table 27. (5.) Results by individual review - epidural (Continued)

Sense of control in labour (feel-

ings of poor control)

1 (344 women) RR 1.17, 95% CI 0.62 to 2.21,


ference


perience

1 (332 women) RR 0.95, 95% CI 0.87 to 1.03,


ference


baby interaction



Assisted vaginal birth 23 (7935 women) RR 1.42, 95% CI 1.28 to 1.


the epidural group had assisted

vaginal birth

Caesarean section 27 (8417 women) RR 1.10, 95% CI 0.97 to 1.25,


ference

Caesarean section for fetal dis-

tress

11 (4816 women) RR 1.43, 95% CI 1.03 to 1.

97, 11 trials, an increased risk

of caesarean section for fetal dis-

tress


(long-term backache)

3 (1806 women) RR 0.96, 95% CI 0.86 to 1.07,


ference


ternal hypotension)

8 (2789 women) RR 18.23, 95% CI 5.09 to

65.35, (random effects: hetero-

geneity: I2 = 47%, Tau2 = 1.57,


0.07), significantly greater risk

of hypotension in women in the

epidural group



1 (313 women) RR 0.63, 95% CI 0.38 to 1.05,


ference

Adverse effects for women (mo-

tor blockade)

3 (322 women) RR 31.67, 95% CI 4.33 to 231.

51, significantly greater risk of

motor blockade in women in

the epidural group





(headache)

3 (1198 women) RR 0.96, 95% CI 0.81 to 1.15,


ference


sea and vomiting)


to 1.27, random effects: hetero-

geneity: I2 = 49%, Tau2 = 0.09,


0.03), no evidence of a signifi-

cant difference

Adverse effects for women (it-

ching)

3 (230 women) RR 1.46, 95% CI 0.51 to 4.16,


ference


(fever)

6 (2741 women) RR 3.34, 95% CI 2.63 to 4.23,

significantly greater risk of fever

in women in the epidural group


(shivering)

1 (20 women) RR 5.00, 95% CI 0.27 to 92.


difference


(drowsiness)



geneity I2 = 94%, Tau2 = 3.47,

Chi2 test for heterogeneity P <

0.00001), no evidence of a sig-

nificant difference

Adverse effects for women (uri-

nary retention)

3 (283 women) RR 17.05, 95% CI 4.82 to 60.

39, significantly greater risk of

urinary retention in women in

the epidural group


(catheterization during labour)

2 (1103 women) RR 1.81, 95% CI 0.44 to 7.46,


ference

Adverse effects for women (mal-

position)

4 (673 women) RR 1.40, 95% CI 0.98 to 1.99,


ference

Adverse effects for women (sur-

gical amniotomy)



geneity I2 = 81%, Tau2 = 0.05,



cant difference




Adverse effects for infants (aci-

dosis pH less than 7.2)

7 (3643 women) RR 0.80, 95% CI 0.68 to 0.

94, neonates of women who

had epidural had a significantly

lower risk of acidosis

Adverse effects for infants (aci-

dosis pH less than 7.15)

2 (382 women) RR 0.95, 95% CI 0.50 to 1.79,


ference


(naloxone administration)

10 (2645 women) RR 0.15, 95% CI 0.10 to 0.

23, neonates of women who

had epidural had a significantly

lower risk of requiring naloxone


(meconium staining of liquor)

5 (2295 women) RR 1.01, 95% CI 0.84 to 1.21,


ference



unit

7 (3125 women) RR 1.19, 95% CI 0.94 to 1.50,


ference


five minutes

18 (6898 women) RR 0.80, 95% CI 0.54 to 1.20,


ference


term follow-up






Table 28. (6.) Results by individual review - combined spinal epidural

6. Combined spinal-epidural versus epidural in labour, 27 studies, 3303 women (Simmons 2012)

Combined spinal-epidural

versus traditional epidural


Pain intensity - time from first

injection to effective analgesia

in minutes

2 (129) MD -2.87, 95% CI -5.07 to -0.

67, CSE had a faster onset time of

effective pain relief from time of

injection (approximately 3 min-



Table 28. (6.) Results by individual review - combined spinal epidural (Continued)

utes)




perience



tion




fewer assisted vaginal births in the

CSE group





dual puncture)

3 (188) RR 3.78, 95% CI 0.16 to 89.09,




(known dural tap)

3 (842) RR 2.77, 95% CI 0.66 to 11.65,



Adverse effects for women (pru-

ritus)

6 (370) Average RR 7.34, 95% CI 0.14

to 375.82, (random effects; het-

erogeneity: I2 = 97%, Tau2 = 15.


<0.00001), there was no signifi-

cant difference between groups


nary retention)

1 (704) RR 0.86, 95% CI 0.79 to 0.95,

fewer women in the CSE group

experienced urinary retention


sea/vomiting)

6 (370) Average RR 1.48, 95% CI 0.55


geneity: I2 = 59%, Tau2 = 0.51,


06), no significant difference be-

tween groups





potension)

6 (1002) Average RR 0.81, 95% CI 0.65

to 1.02, no significant difference

between groups


(headache)

1 (79) RR 1.03, 0.07 to 15.83, no

significant difference between

groups

Adverse effects for women (se-

dation)

1 (79) RR 1.03, 0.46 to 2.31, no signif-

icant difference between groups

Adverse effects for infants Outcome not reported in suitable

format



1 (704) RR 0.63, 95% CI 0.29 to 1.37,


groups


five minutes

3 (842) RR 2.10, 95% CI 0.63 to 6.97,




term follow-up



Combined spinal-epidural

versus low-dose epidural




in minutes

5 (461) Average Mean difference MD -

5.42, 95% CI -7.26 to -3.59,


for heterogeneity P =0.002), CSE

had a faster onset time of effective

pain relief from time of injection

(approximately 6 minutes)


women with effective analgesia

10 minutes after first injection

1 (101) RR 1.94, 95% CI 1.49 to 2.54,

more women in the CSE group

had effective analgesia






groups



perience



tion










dual puncture)

9 (701) RR 1.68, 95% CI 0.42 to 6.81,




(known dural tap)

6 (1326) RR 0.81, 95% CI 0.22 to 2.98,




(number of women requiring

blood patch for post dural

puncture headache)

7 (531) RR 2.22, 95% CI 0.51 to 9.64,



Adverse effects for women (pru-

ritus)

11 (959) Average RR 1.80, 95% CI 1.22


geneity: I2 = 84%, Tau2 = 0.26,


00001), more women in the CSE

group had pruritus


nary retention)

4 (964) RR 1.05, 95% CI 0.94 to 1.16,







sea/vomiting)

7 (539) Average RR 0.97, 95% CI 0.65 to




potension)

14 (2040) Average RR 1.35, 95% CI 0.89


geneity: I2 = 50%, Tau2 = 0.13,





(headache any)

1 (110) RR 0.14, 0.01 to 2.70, no evi-

dence of a significant difference

between groups

Adverse effects for infants Outcome not reported in suitable

format



3 (852) RR 0.77, 95% CI 0.34 to 1.73,

no evidence of significant differ-

ence between groups


five minutes

6 (1092) RR 0.70, 95% CI 0.31 to 1.59,




term follow-up




Table 29. Results by individual review - sterile water injection, Hutton 2009

Sterile water injection for labour pain: a systematic review and meta-analysis of randomised controlled trials 8 studies, 783

women (Hutton 2009)

Sterile water injections versus

placebo or other treatment


Pain intensity - VAS pain score

at 10-30 minutes following in-

tervention


26.04, 95% CI -34.14.0 to -

17.94, (random effects: hetero-

geneity: I2 = 65%, Tau2 = 41.


=0.04), , a significant reduction



Table 29. Results by individual review - sterile water injection, Hutton 2009 (Continued)

in pain score of the sterile water

group compared with the placebo

or other intervention group

Pain intensity - Pain intensity -

VAS pain score at 45-60 min-

utes following intervention


36.27, 95% CI -50.80 to -21.

74, (random effects: heterogene-

ity: I2 = 94%, Tau2 = 255.58,

Chi2 test for heterogeneity P <=

0.00001), a significant reduction




Pain intensity - Pain intensity -

VAS pain score at 90-120 min-

utes following intervention


27.74, 95% CI -39.03 to -16.

45, (random effects: heterogene-

ity: I2 = 86%, Tau2 = 135.71,

Chi2 test for heterogeneity P <=

0.00001), a significant reduction







perience



tion





significantly fewer caesarean sec-

tions in the sterile water group

compared with the placebo or

other intervention group

Side effects for mother Outcome not reported

Side effects for baby Outcome not reported



Table 29. Results by individual review - sterile water injection, Hutton 2009 (Continued)





five minutes



term follow-up



CI: confidence interval; MD: mean difference; RR: risk ratio; VAS: visual analogue scale

Table 30. Results by individual review - epidural ropivacaine vs bupivacaine, Halpern 2003

Epidural ropivacaine versus bupivacaine for labor: a meta-analysis, 23 studies, 2074 women (Halpern 2003a)

Ropivacaine versus bupiva-

caine




in minutes

9 (755) MD 0.66, 95% CI -1.0 to 2.31,



Satisfaction with pain relief 11 (672) OR 1.07, 95% CI 0.73 to 1.59,





perience



tion



Assisted vaginal birth 18 (1787) OR 0.89, 95% CI 0.67 to 1.18,



Caesarean section 19 (1831) OR 0.88, 95% CI 0.67 to 1.14,





Table 30. Results by individual review - epidural ropivacaine vs bupivacaine, Halpern 2003 (Continued)

Side effects for mother (hy-

potension)

9 (615) OR 1.04, 95% CI 0.60 to 1.8,



Side effects for mother (nausea

or vomiting)

7 (888) OR 0.88, 95% CI 0.59 to 1.29,



Side effects for baby Outcome not reported in suitable

format





five minutes

15 (1550) OR 0.99, 95% CI 0.49 to 2.0,




term follow-up



CI: confidence interval; MD: mean difference; OR: odds ratio

Table 31. Results by individual review - intrathecal opioids - Mardirosoff 2002

Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review, 24 studies, 3513 women (Mardirosoff

2002)

Intrathecal opioids versus

non-intrathecal opioids






perience



tion





Table 31. Results by individual review - intrathecal opioids - Mardirosoff 2002 (Continued)







Opioids in controls Adverse effects for women (pru-

ritus)

9 (1308) Average RR 1.71, 95% CI 0.97 to



No opioids in controls Adverse effects for women (pru-

ritus)

11 (855) RR 29.6, 95% CI 13.6 to 64.

6, significantly more pruritus in

women in the intrathecal opioid

group


heart rate abnormalities)

17 (2081) RR 1.17, 95% CI 0.87 to 1.57,




bradycardia within 1 hour)

9 (927) OR 1.81, 95% CI 1.04 to 3.14,

significant increase in fetal brady-

cardia with intrathecal opioids





five minutes

11 (1623) OR 1.17, 95% CI 0.44 to 3.11,




term follow-up



CI: confidence interval; OR: odds ratio; RR: risk ratio

Table 32. Summary of outcomes reported in Cochrane systematic reviews - pharmacological interventions

Inhaled analgesia

(Klomp 2012)

Parenteral

opioids review (

Ullman 2010)

Non-opioid

drugs (Othman

2012)

Local anaesthetic

nerve blocks (

Novikova 2012)

Epidural (Anim-

Somuah 2011)

Combined

spinal epidural (

Simmons 2012)



Table 32. Summary of outcomes reported in Cochrane systematic reviews - pharmacological interventions (Continued)

Pain intensity 9/26

trials (26%) re-

ported this out-

come

Significant find-

ings observed for

4 comparisons (7

studies)

28/57

trials (49%) re-

ported this out-

come

Significant find-

ings observed for

5 comparisons (8

studies)

2/18 trials (11%)

reported this

outcome

Significant find-

ings observed for

1 comparison (1

study)

NOT

REPORTED

7/38 trials (18%)

reported this

outcome

Significant find-

ings observed for

3 comparisons (7

studies)

8/27

trials (30%) re-

ported this out-

come

Significant find-

ings observed for

3 comparisons (8

studies)

Satisfaction with

pain relief

8/26 trials (31%)

reported this

outcome

No differences

observed

between groups

12/57 trials

(21%)

reported this

outcome

Significant find-

ings observed for

2 comparisons (2

studies)

9/18 trials (50%)

reported this

outcome

Significant find-

ings observed for

5 comparisons (7

studies)

6/12

trials (50%) re-

ported this out-

come

Significant find-

ings observed for

2 comparisons (2

studies)

9/38 trials (24%)

reported this

outcome

No differences

observed

between groups

7/27

trials (26%) re-

ported this out-

come

No differences

observed

between groups

Sense of control

in labour

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

1/38 trials (3%)

reported this

outcome

No differences

observed

between groups

NOT

REPORTED

Satisfaction with

childbirth expe-

rience

NOT

REPORTED

1/57

trial (1.75%) re-

ported this out-

come

No differences

observed

between groups

1/18 trials (6%)

reported this

outcome

Significant find-

ings observed for

1 comparison (1

study)

NOT

REPORTED

1/38 trials (3%)

reported this

outcome

No differences

observed

between groups

NOT

REPORTED

Effect on

mother/baby in-

teraction

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

Breastfeeding NOT

REPORTED

2/57

trials (3.5%) re-

ported this out-

come

No differences

observed

between groups

1/18 trials (6%)

reported this

outcome

No differences

observed

between groups

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED




Assisted vaginal

birth

7/26

trials (27%) re-

ported this out-

come

No differences

observed

between groups

17/57 trials

(30%)

reported this

outcome

No differences

observed

between groups

7/18 trials (39%)

reported this

outcome

No differences

observed

between groups

3/12

trials (25%) re-

ported this out-

come

No differences

observed

between groups

23/38

trials (60%) re-

ported this out-

come

Signifi-

cant findings ob-

served for 1 com-

parison (23 stud-

ies)

17/27

trials (63%) re-

ported this out-

come

Significant find-

ings observed for

1 comparison (6

studies)

Caesarean

section

6/26

trials (23%) re-

ported this out-

come

No differences

observed

between groups

20/57 trials

(35%)

Reported this

outcome

No differences

observed

between groups

3/18

trials (17%) re-

ported this out-

come

No differences

observed

between groups

4/12

trials (33%) re-

ported this out-

come

No differences

observed

between groups

27/38

trials (71%) re-

ported this out-

come

No differences

observed

between groups

21/27

trials (78%) re-

ported this out-

come

No differences

observed

between groups

Adverse effects

for women

16/26

trials (62%) re-

ported this out-

come

Significant find-

ings observed for

7 comparisons (9

studies)

35/57

trials (62%) re-

ported this out-

come

Significant find-

ings observed for

14 comparisons

(27 studies)

6/18 trials (33%)

reported this

outcome

No differences

observed

between groups

2/12 trials (17%)

reported this

outcome

Significant find-

ings observed for

1 comparison (1

study)

21/38

trials (55%) re-

ported this out-

come

Significant find-

ings observed for

4 comparisons

(12 studies)

16/27

trials (60%) re-

ported this out-

come

Significant find-

ings observed for

2 comparisons

(12 studies)

Adverse effects

for infants

4/26

trials (15%) re-

ported this out-

come

No differences

observed

between groups

17/57

trials (30%) re-

ported this out-

come

Significant find-

ings observed for

1 comparison (1

study)

5/18 trials (28%)

reported this

outcome

No differences

observed

between groups

1/12 trials (8%)

reported this

outcome

Significant find-

ings observed for

1 comparison (1

study)

18/38

trials (47%) re-

ported this out-

come

Significant find-

ings observed for

2 comparisons

(15 studies)

NOT

REPORTED

Admission to

special care baby

unit/neonatal in-

tensive care unit

NOT

REPORTED

6/57 trials (10%)

reported this

outcome

No differences

observed

between groups

NOT

REPORTED

NOT

REPORTED

7/38 trials (18%)

reported this

outcome

No differences

observed

between groups

4/27

trials (15%) re-

ported this out-

come

No differences

observed

between groups




Apgar score less

than seven at five

minutes

7/26

trials (27%) re-

ported this out-

come

No differences

observed

between groups

12/57

trials (21%) re-

ported this out-

come

No differences

observed

between groups

4/18 trials (22%)

reported this

outcome

No differences

observed

between groups

4/12 trials (33%)

reported this

outcome

No differences

observed

between groups

18/38

trials (47%) re-

ported this out-

come

No differences

observed

between groups

9/27

trials (33%) re-

ported this out-

come

No differences

observed

between groups

Poor infant out-

comes at long-

term follow-up

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

Cost NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

NOT

REPORTED

Table 33. Summary of outcomes reported in Cochrane systematic reviews - non-pharmacological interventions

Hypnosis (

Madden

2012

Biofeed-

back

(Barragán

2011)

Sterile wa-

ter

injection (

Derry

2012)

Immer-

sion in wa-

ter (Cluett

2009)

Aro-

mather-

apy (Smith

2011c)

Relaxation

techniques

(Smith

2011b)

Acupunc-

ture

or acupres-

sure

(Smith

2011a)

Massage,

reflexology

&

other man-

ual meth-

ods (Smith

2012)

TENS

(Dowswell

2009)

Pain inten-

sity

1/7 trials

(14%) re-

ported this

outcome

Signif-

icant find-

ings ob-

served for

1 compari-

son

(1 study) -

but

this was a

quasi-

RCT

NOT RE-

PORTED

3/7 trials

(43%) re-

ported this

outcome

Signif-

icant find-

ings ob-

served for

10 com-

parisons (3

studies)

4/12 trials

(33%) re-

ported this

outcome

Signif-

icant find-

ings ob-

served for

10 com-

parisons (1

study)

NOT RE-

PORTED

5/11 trials

(45%) re-

ported this

outcome

Significant

findings

observed

for 3 com-

parisons (3

studies)

7/13 trials

(54%) re-

ported this

outcome

Significant

findings

observed

for 3 com-

parison (4

studies)

5/6 trials

(83%) re-

ported this

outcome

Significant

findings

observed

for 2 com-

parisons (5

studies)

10/17 tri-

als

(59%) re-

ported this

outcome

Significant

findings

observed

for 2 com-

parisons (3

studies)

Satisfac-

tion with

pain relief

1/7 trials

(14%) re-

ported this

outcome

No differ-

ences ob-

NOT RE-

PORTED

NOT RE-

PORTED

NOT ) NOT RE-

PORTED

3/11 trials

(27%) re-

ported this

outcome

Significant

3/13 trials

(23%) re-

ported this

outcome

Significant

2/6 trials

(33%) re-

ported this

outcome

6/17 trials

(35%) re-

ported this

outcome

Significant



Table 33. Summary of outcomes reported in Cochrane systematic reviews - non-pharmacological interventions (Continued)

served be-

tween

groups

findings

observed

for 2 com-

parisons (2

studies)

findings

observed

for 2 com-

parisons (2

studies)

No differ-

ences ob-

served be-

tween

groups

findings

observed

for 1 com-

parison (1

study)

Sense of

control in

labour

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

1/6 trials

(17%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

Satisfac-

tion

with child-

birth expe-

rience

2/7 trials

(28%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

1/12 trial

(8%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

2/11 trials

(18%) re-

ported this

outcome

Significant

findings

observed

for 1 com-

parison (1

study)

1/13 trials

(7%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

Effect on

mother/

baby inter-

action

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

Breastfeed-

ing

1/7 trials

(14%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

3/12 trials

(25%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

As-

sisted vagi-

nal birth

3/7 trials

(43%) re-

ported this

outcome

No differ-

ences ob-

2/4 trials

(50%) re-

ported this

outcome

No differ-

ences ob-

6/7 trials

(86%) re-

ported this

outcome

No differ-

ences ob-

8/12 trials

(67%) re-

ported this

outcome

No differ-

ences ob-

2/2 trials

(100%) re-

ported this

outcome

No differ-

ences ob-

3/11 trials

(27%) re-

ported this

outcome

Significant

findings

7/13 trials

(54%) re-

ported this

outcome

Signif-

icant find-

2/6 trials

(33%) re-

ported this

outcome

No differ-

11/17 tri-

als

(65%) re-

ported this

outcome




served be-

tween

groups

served be-

tween

groups

served be-

tween

groups

served be-

tween

groups

served be-

tween

groups

observed

for 1 com-

parison (2

studies)

ings ob-

served for

one com-

parison (1

study)

ences ob-

served be-

tween

groups

Signficant

findings

observed

for 1 com-

parison (1

study)

Caesarean

section

3/7 trials

(43%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

2/4 trials

(50%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

7/7 trials

(100%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

9/12 trials

(75%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

2/2 trials

(100%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

4/11 trials

(36%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

9/13 trials

(69%) re-

ported this

outcome

Signif-

icant find-

ings ob-

served for

one com-

parison (1

study)

2/6 trials

(33%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

13/17 tri-

als

(76%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

Adverse ef-

fects for

women

1/7 trials

(14%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

1/7 trials

(14%) re-

ported this

outcome

Significant

findings

observed

for 2 com-

parisons (1

study)

10/12 tri-

als

(83%) re-

ported this

outcome

Significant

findings

observed

for 3 com-

parisons (1

study)

1/2 trials

(50%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

Adverse ef-

fects for in-

fants

1/7 trials

(14%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

10/12 tri-

als

(83%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

2/17 trials

(12%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

Ad-

mission to

special care

baby unit/

neonatal

intensive

care unit

2/7 trials

(28%) re-

ported this

outcome

No differ-

ences ob-

served be-

NOT RE-

PORTED

NOT RE-

PORTED

4/12 trials

(33%) re-

ported this

outcome

No differ-

ences ob-

served be-

2/2 trials

(100%) re-

ported this

outcome

No differ-

ences ob-

served be-

NOT RE-

PORTED

NOT RE-

PORTED

1/6 trials

(17%) re-

ported this

outcome

No differ-

NOT RE-

PORTED




tween

groups

tween

groups

tween

groups

ences ob-

served be-

tween

groups

Apgar

score less

than seven

at five min-

utes

1/7 trials

(14%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

7/12 trials

(58%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

5/13 trials

(38%) re-

ported this

outcome

No differ-

ences ob-

served be-

tween

groups

NOT RE-

PORTED

NOT RE-

PORTED

Poor

infant out-

comes at

long-term

follow-up

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

Cost NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

NOT RE-

PORTED

RCT: randomised controlled trial

A P P E N D I C E S

Appendix 1. Search strategies for non-Cochrane reviews

Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 2 of 4)

#1 MeSH descriptor Labor Pain explode all trees

#2 labor or labour or birth or childbirth

#3 pain or analges*

#4 MeSH descriptor Analgesia, Obstetrical explode all trees

#5 (#2 AND #3)

#6 (#1 OR #4 OR #5)

MEDLINE (via OVID) (1966 to 31 May 2011)

1. (“review” or “review academic” or “review tutorial”).pt.

2. (medline or medlars or embase or pubmed).tw,sh.

3. (scisearch or psychinfo or psycinfo).tw,sh.

4. (psychlit or psyclit).tw,sh.

5. cinahl.tw,sh.

6. ((hand adj2 search$) or (manual$ adj2 search$)).tw,sh.



7. (electronic database$ or bibliographic database$ or computeri?ed database$ or online database$).tw,sh.

8. (pooling or pooled or mantel haenszel).tw,sh.

9. (retraction of publication or retracted publication).pt.

10. (peto or dersimonian or der simonian or fixed effect).tw,sh.

11. or/2-10

12. 1 and 11

13. meta-analysis.pt.

14. meta-analysis.sh.

15. (meta-analys$ or meta analys$ or metaanalys$).tw,sh.

16. (systematic$ adj5 review$).tw,sh.

17. (systematic$ adj5 overview$).tw,sh.

18. (quantitativ$ adj5 review$).tw,sh.

19. (quantitativ$ adj5 overview$).tw,sh.

20. (quantitativ$ adj5 synthesis$).tw,sh.

21. (methodologic$ adj5 review$).tw,sh.

22. (methodologic$ adj5 overview$).tw,sh.

23. (integrative research review$ or research integration).tw.

24. or/13-23

25. 12 or 24

26. exp Labor Pain/

27. exp Analgesia, Obstetrical/

28. (labor or labour or childbirth or birth).mp. and (pain* or analges*).tw.

29. exp Anesthesia, Obstetrical/

30. 26 or 27 or 28 or 29

31. 25 and 30

EMBASE (via NHS Evidence Health Information Resources) (1980 to 31 May 2011)

1. exp REVIEW/

2. (medline OR medlars OR embase OR pubmed).af

3. (psycinfo OR psychinfo).af

4. cinahl.af

5. (((hand adj2 search$) OR (manual$ ADJ search$))).ti,ab

6. (((electronic ADJ database$) OR (bibliographic ADJ database$))).ti,ab

7. ((pooled ADJ analys$) OR (pooling)).ti,ab

8. (peto OR dersimonian OR (fixed ADJ effect) OR mantel AND haenszel).ti,ab

9. RETRACTED ARTICLE/

10. (scisearch OR psychlit OR psyclit).af

11. 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10

12. 1 AND 11

13. exp META ANALYSIS/

14. meta?analys$.af

15. (systematic$ adj5 review$).af

16. (systematic$ adj5 overview$).af

17. (quantitativ$ adj5 review$).af

18. (quantitativ$ adj5 overview$).af

19. (methodologic$ adj5 review$).af

20. (methodologic$ adj5 overview$).af

21. ((integrative adj5 research adj5 review$) OR (research adj5 integration)).ti,ab

22. (quantitativ$ adj5 synthesi$).af

23. 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22

24. 12 OR 23

25. exp LABOR PAIN/

26. exp OBSTETRIC ANALGESIA/

27. exp OBSTETRIC ANESTHESIA/



28. ((labor OR labour OR birth OR childbirth) AND (pain* OR analges*)).ti,ab

29. 25 OR 26 OR 27 OR 28

30. 24 AND 29

Systematic review search filters (lines 1-25 in the MEDLINE search and 1-24 in the EMBASE search) taken from the Clinical Evidence

website. The EMBASE filter was adapted for the NHS Evidence Health Information Resources version of EMBASE.

W H A T ’ S N E W

Last assessed as up-to-date: 31 October 2011.

Date Event Description

20 May 2013 Amended Number of new (6) and updated (9) Cochrane reviews corrected in the Abstract. NIHR acknowledge-

ment added

C O N T R I B U T I O N S O F A U T H O R S

James Neilson and Zarko Alfirevic conceived the idea of the overview. Leanne Jones, Mohammad Othman and Therese Dowswell

assessed review eligibility and carried out all data extraction and data entry. Therese Dowswell and Leanne Jones co-authored initial

drafts of the overview. James Neilson, Zarko Alfirevic, Simon Gates, Mary Newburn, Sue Jordan and Tina Lavender commented on

draft versions of the protocol and the final overview.

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

• The University of Liverpool, UK.

External sources

• National Institute for Health Research, UK.

Cochrane-NHS Engagement Project No: 10/4000/02



http://clinicalevidence.bmj.com/ceweb/about/search_filters.jsp

http://clinicalevidence.bmj.com/ceweb/about/search_filters.jsp

N O T E S

In future updates the relaxation techniques and manual methods reviews will be split into separate reviews on yoga, music, audio and

massage and reflexology, respectively.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Acupuncture Analgesia; Administration, Inhalation; Analgesia, Epidural [adverse effects; methods]; Analgesia, Obstetrical [adverse

effects; ∗methods]; Analgesics [administration & dosage; adverse effects]; Cesarean Section [utilization]; Immersion; Labor Pain

[∗therapy]; Massage; Patient Satisfaction; Relaxation Therapy [methods]; Review Literature as Topic

MeSH check words

Female; Humans; Pregnancy



pain management for women in labour: an overview of

Documents